Dear crew: This draft is open to comments/suggestions. Please pardon the
variations in citations at this time. We also need to add more recommendations.
Thank you. Kem & Jean
AACP Academic Affairs Committee
Affordability Sub-Committee Report
Disruptive innovation is when technology is applied in way that creates a simpler, more
affordable product for a new group of customers who, in most cases, were not buying
(or succeeding in) the traditional offering.1
One must take on a systems approach when discussing the three pressures on college
education: affordability; access and accountability. Coined the “Iron Triangle” by John
Immerwahr et al., these pressures must be kept in balance as an intervention in one
area affects one or both of the other areas.2 For example, drops in the numbers of
applicants and intense competition from increased numbers of pharmacy programs for
dwindling numbers over recent years has forced colleges of pharmacy to consider
applicants with uneven academic preparation for professional program work. As a
result, advance programming has been developed to better prepare matriculating
students for the challenges of professional graduate education. And, for some colleges,
efforts to market to a greater audience and recruit has resulted in increased costs.
Greater demands for accountability and assessment from ACPE has required
reallocation of funds to staff assessment personnel. Finally, the current trend of
experiential sites mandating payment to serve as experiential sites for introductory and
advanced experiential sites has challenged College of Pharmacy budgets.
Given these pressures, higher education may have become too expensive and too
cumbersome to achieve its academic mission and to balance the “Iron Triangle.” The
increased price of higher education with a much slower increase in family incomes has
led to increased indebtedness; and, for some students, pressures to work while in
school or even to defer school entry.3
The focus of this section of the report is on affordability. Is higher education
unaffordable? In what Selingo calls the “lost decade”, i.e., before the financial crisis of
2008, enrollments increased rather than declined despite increases in tuition over the
years, demonstrating a willingness and ability to pay. However, four forces have
impacted the higher education business model and economic viability after 2008: 1)
unsustainable financial statements weaker than before the recession; 2) dwindling state
funding; 3) numbers of full-paying students diminishing; 4) unbundled alternatives at a
lower price being made available via online education and non-credential means of
showing learning such as badge systems; and, 5) a growing value gap, i.e., college
A ‘Disruptive’ Look at Competency-Based Education How the Innovative Use of Technology Will
Transform the College Experience Louis Soares June 2012 Center for American Progress.
2 The Iron Triangle: College Presidents Talk about Costs, Access, and Quality, John Immerwahr, Jean
Johnson and Paul Gasbarra, A Report from The National Center for Public Policy and Higher
Education and Public Agenda, October, 2008.
3 National Center for Public Policy and Higher Education, Losing Ground, 2004
1
graduates questioning the value of their education given the tough economy and
student-loan debt burden.4
“Affordability is the degree to which an institution or program provides a
combination of tuition, fees, grants, loans, and time-to-completion that make
worthwhile a student’s investment in his/her education.” Affordability is a key
component of the business models of competency based education programs,
which often aim to reduce students’ costs through a variety of delivery models.”5
Our goals are to explore: 1) trends in higher education costs in general and in pharmacy
schools specifically; 2) models of factors that affect costs of higher (pharmacy)
education; 3) ways can we increase perceived value of pharmacy education, including
potential means to make pharmacy education more affordable and/or help students
manage/decrease their debt burden; and finally, 4) a rethinking of current curriculum
models towards providing individualized, flexible, competency-based programs
consistent with development of professional values of self-assessment and continual
learning so students, the profession and society can be assured all graduates have been
adequately prepared by having to meet competency assessments.
1) Explore trends in higher education costs in general and in pharmacy schools
specifically
The average pharmacy tuition for public institution has increased. In-state tuition
(adjusted for inflation) at public four-year institutions increased from $2,242 in 1981 to
$8,244 in 2011 (4.4% higher than the inflation rate). Private institutions have seen
similar increases from $10,144 to $28,500 (in 2011 dollars). Similarly, between 1998
and 2013 the proportion of pharmacy school revenue generated by tuition increased
from 4.6% to 14% at public intuitions and dropped from 72.5% to 67% at private
institutions.
Assuming that rising tuition is a result of rising costs is reasonable since the price
charged (i.e. tuition) must cover the cost of production plus a nominal profit. However,
the observed tuition increases may actually result from a change in the composition of
the revenue stream rather than simply increased costs (McPherson and Shulenburger,
2010). In higher education the relationship between cost and price is not so clear
because the higher education revenue streams can be comprised of tuition, government
support, sales of goods and services, indirect research support. The composition of the
revenue stream may vary widely between public non-profit, private non-profit, and
public for-profit organizations.
4
Jeffrey J. Selingo, College (Un) Bound, Houghton Mifflin Harcourt Publishing, 2013.
Clarifying competency based education terms, American Council on Education and
Blackboard
5
State governments have used the power of the public purse in an attempt to force
greater operational efficiencies in public instituitions; however, tuitions have increased
as state appropriations have decreased. The contribution of state appropriation as a
percent of total revenue for public research institutions dropped from 54% to 46%
between 1987 and 2006. During this same period tuition increased 132%. The tuition
increase generated slightly more revenue than that lost by state cutbacks (McPherson
and Shulenburger, 2010). State allocations comprised 42% of pharmacy school revenue
in 1997-98 compared to 22% in 2012-13. It is plausible that increases in state funding
were not sufficient to offset increases in faculty salary and operational expenses to
support the education mission of pharmacy schools. Tuition increases made up for the
short-fall.
2) Explore models of factors that affect costs of higher (pharmacy) education
Given the complex nature of the higher education business model, a two-part higher
education cost model is used to examine cost associated with pharmacy education. The
model was originally created to help policy makers understand the cost structure of
public research universities (McPherson and Shulenburger, 2010). University costs can
be divided into two parts: 1) cost centers that generate their own revenue such as
research, clinical services, residence halls, dining facilities, athletics, bookstore and
other retail outlets and 2) the costs of student education that is paid for by a
combination of state appropriations, tuition and philanthropy (McPherson and
Shulenburger, 2010). All of these areas contribute to the cost of running an institution
of higher education, whether or not they generate revenue. However, the cost centers
that generate their own revenue are expected to be self-sustaining or revenue
generating.
The two-part model appears to be relevant to pharmacy education based on financial
survey data collected by AACP. Between 1998 and 2013 the average cost (adjusted for
inflation) per public school increased 71% while average revenues increased 128%.
Increases in operational costs and salaries accounted for most of the change. Tuition
increases accounted for 21% of the increased revenue, increases in state funding
accounted for 7%. The bulk of the increased revenues came from enterprises other
than tuition, state funds, research and gifts. After adjusting for inflation, the average
increase in expenses per private school was 12% and the average revenue increase was
15%. Tuition increases and increased allocations from campus accounted for the bulk of
the increased revenue among private schools. Increased salaries and benefits
accounted for most of the increased expenditures.
In 1997 the AACP-appointed Janus Commission proposed a production model for
pharmacy education that was consistent with the two-part model described above. The
Commission urged schools/colleges of pharmacy to update their programs to prepare
graduates for the rapidly changing healthcare environment. To meet these challenges,
the Commission recommended (among other things) that schools “secure and expand
pharmacy schools’ financial base beyond student tuition and state support”.6 As the
healthcare environment continues to change, curricular reform is as important today as
it was in 1997. Because curricular change requires a tremendous amount of resources
and has significant impact on the student experience, it is useful to break down the
process of education into its various components.
A taxonomy of educational experience, created by Michael Staton to describe the
educational component part of higher education that shape the student’s education,
provides a useful framework to examine the implications of student expectations on
process and costs of delivering a quality education. The four main components of the
model include the Component Loop; Access to Opportunities; Meta-content and Skills
Development; and Transformative Experiences (Figure 1)7.
The Component Loop encompasses the traditional steps required to prepare and deliver
material in a didactic setting. This includes content authoring and production; planning
the sequencing and pathways for delivering the content; and finally transferring the
content to students via lecture and learning activities. It is in this area where disruptive
technologies and methods such as the use of technology to provide distance education
challenge the traditional model of pharmacy education provision. Members of the
academy should determine if our efforts in this endeavor could be accomplished more
cost-effectively and/or at a higher quality.
A second component, Meta-content and Skills, describes the opportunities given to
students to develop new models of thinking and doing; performance practice and
feedback leading to mastery; and enduring monitoring, coaching, apprenticeship, and
supervision. On-time feedback mechanisms, reflective, laboratory and experiential
education activities are vital for these areas of development. Are there sufficient active
and reflective learning activities provided to pharmacy students so they develop deep
vs. surface learning? Do we offer a sufficient number and variety of activities for each
student? Is there a way to enhance these experience based opportunities or improve
their quality? Are there opportunities for deep versus surface learning in the
curriculum? The tendency for surface learning occurs with heavy student workloads,
lower order learning objectives, passive learning as in traditional lectures, material
perceived to be irrelevant.8 While subject content is important, it is the meta-content
and skills that are highly valued and that make the effective health professional.
6
“Approaching the Millennium: The Report of the AACP Janus Commission,” Am. Jour. of Pharm. Educ.,
61, 4S-10S, (1997)
7
Michael Staton, Unbundling Higher Education: Taking Apart the Components of the College Experience,
in Stretching the Higher Education Dollar, Andrew P. Kelly and Kevin Carey, eds., Harvard Education Press.
Cambridge: Year??
8
Centre for Teaching and Learning Good Practice in Teaching and Learning, Deep,
surface and strategic approaches to learning Contributor: Jackie Lublin,
http://www2.warwick.ac.uk/services/ldc/development/pga/introtandl/resources/2a_deep_surfacestrate
gic_approaches_to_learning.pdf
The third component of the taxonomy, Access to Opportunities, includes the processes
necessary for personal and career development such as feedback that the student is
learning and developing an affiliate network with other students, faculty, and practicing
pharmacists. When evaluating a school’s performance on this component questions
about student feedback from assessments, networking and extra-curricular
opportunities for professional networking should be examined.
The fourth component, Transformative Experiences, describes the necessary rites of
passage for professional socialization and transformation from lay to professional.
These could occur during experiential or didactic educational experiences or while
engaging in extra-curricular activities. Is a safe and supportive environment provided for
students to explore and push the boundaries of their comfort zones? What
technological or human resources could be deployed to develop and support students’
intellectual curiosity?
Figure 1. Educational Component of Higher Education: Disaggregating the
Components of a College Degree 6
The economic downturn of 2008 was the “beginning of the end” of a decade of
university excess.9 Several large research universities hired national consulting firms to
review their operations and recommend cost saving strategies. Although the
consultants did not address the teaching or research endeavors, they did identify
several drivers of inefficiency within higher education--namely, redundant systems,
unneeded administrative complexity, lack of standardization, and misaligned incentives.
Examples of redundant systems within a department, college or across the university
include bookkeeping systems, IT/email systems, and other data collection systems.
Hierarchical growth, or administrative bloat as it is sometimes called, occurs for a
number of reasons including the growth of complex systems, as a reward for long-time
employees, and to address external mandates to name a few. A 2010 report by the
Goldwater Institute found that inflation-adjusted spending on higher education
administration increased 61% over a 14-year period ending 2007 compared to a 39%
increase in instructional spending over the same time period.10
Lack of standardization comes down to purchasing power. Many of the universities
cited didn’t have central purchasing or prime vendors and were unable to negotiate
volume discounts on everything from computers to paper to teaching and research
supplies. The consultants also highlighted the decision-making paradox in higher
education. Both tangible and intangible costs exists for making the wrong decisions in
higher education, however fewer penalties exist for making no decision or postponing
decisions. This coupled with the strong tradition of shared governance makes it easier
not to make a decision in higher education compared to a corporate environment.
Additionally the common cost-cutting techniques used when a university is facing
budget cuts such as across the board cuts, hiring freezes, salary cuts/furloughs, cutting
entire programs or departments, and student service cuts often lead to greater
inefficiencies, low moral, and fail to address the long-term overall performance of the
institution.
Because institutions of higher education are mission-driven, non-profit organizations
with sometimes-divergent charges of teaching, research, and service, it is not common
to look at costs, revenue and output from a production function framework. Thus it is
not always common to identify the specific costs or output for a specific endeavor,
making it difficult to assess efficiency and identify strategies for achieving economies of
scope and scale.11
3) Explore ways can we increase perceived value of pharmacy education, including
potential means to make pharmacy education more affordable and/or help students
manage/decrease their debt burden
9
Selingo, p56
Greene, Kisida and Mills 2010
11 Rethinking the Cost Structure of Higher Education, Kelly and Carey 2013 Chapter 5
1010
The components of the aforementioned taxonomy are accomplished through didactic
and experiential education, extra- and co-curricular activities and other processes such
as student services. Cain et al. have suggested students have certain expectations in
exchange for the tuition paid, namely 1) the opportunity to learn; 2) access to
dedicated, expert faculty; 3) a curriculum designed to prepare them for practice; and 4)
access to the necessary human and physical resources to succeed (Cain, Noel, Smith,
Romanelli, 2014).
The extent to which a school can effectively craft and deliver the four components of
the educational experience is the extent to which graduates will perceive value for their
tuition dollars. Data from the AACP Graduating Student Survey indicate an increasing
trend in the percent of pharmacy graduates who do not value their pharmacy education
experience12 The proportion of pharmacy graduates who indicate that they would not
study pharmacy if they were to choose a career again has increased from 6.9% in 2007
to 14% in 2014. While this clearly represents a minority of students, the trend is worth
investigating and alleviating.
Are expectations not being met or are students becoming more disillusioned with the
profession as has been documented in previous research13 With the budget stresses
and strains placed on pharmacy programs, are budgetary shortcuts being taken with
resultant program compromise? With the recent increases in the numbers of pharmacy
graduates and the stabilization of pharmacist demand, are dreams of multiple job offers
and opportunity to be selective being left unfulfilled?
A number of pharmacy schools have tried to make degree attainment more efficient
and adding to perceived value by combining degrees. The joint degree options decrease
the amount of time required to obtain the two degrees individually. This may save
actual tuition and fees and certainly decreases the opportunity costs of being in school.
Based on the AACP Summary of Financial Data for the 2012-13 fiscal year, 25 schools
offered joint PharmD/PhD progams with an average enrollment of four students; 37
offered joint PharmD/MBA programs (average enrollment: 14); 13 offered joint
PharmD/MS programs (average enrollment: 2); 13 offered joint PharmD/MPH programs
(average enrollment: 4); and 6 reported offering other joint degree programs. These
programs can be attractive to optimistic applicants and may affect program selection.
What is unknown and undocumented is the costs associated with administering these
programs.
Decisions to attend specific colleges/schools of pharmacy are made by the applicants,
possibly with the help of parents and/or family. Costs of attending and opportunities
for financial aid and scholarships are paramount in the decision making process when all
other components of the programs/universities are equal. Little is known of the
12
13
AACP, DTaylor
Ref needed.
importance of various university services and components or of their relative weights in
the decision making processes of pharmacy matriculants. A combination of factors may
affect that decision, including pharmacist-friend, pharmacist-employer and/or
pharmacist-family recommendations. Direct, “guaranteed” entry programs such as
offered by 0-5 programs are attractive to high school applicants and their families
wanting the assurance of program admission.
A factor often mentioned when students explain their reasons for selecting the UNE
College of Pharmacy, a private, non-profit institution in Portland, Maine, include how
the faculty, staff and College administration are student-centered and how current
students seem to enjoy being in the program. Applicants and matriculating students are
told (with follow-through) that faculty and services are there to help them be successful.
These program selection decisions may be gut-level at this level of program naiveté—
again with all others things being equal.
Once in a program, students become immersed in the organizational and professional
culture of the institution and learn to appreciate varying opportunities for their careers
and what services the school/program provides that may facilitate their performance
while in school and their preparation for life after graduation, e.g., services or programs
such as opportunities to develop leadership capabilities or to prepare for next-level
training/education (residencies, fellowships, MS/PhD graduate programs). The breadth
of elective course and non-traditional experiential offerings, as well as, formal
mentoring/advising programs and career counseling, development and placement
opportunities can provide individualized assistance and result in satisfaction with the
program and the choice of the pharmacy profession. Availability of honors programs
and opportunities to conduct research open up students’ skill development beyond
typical pharmacy education content and career opportunities.
A current trend in higher education is to help students learn how to handle money and
debt. The Apollo Research Institute conducted a study and discovered the top
psychosocial issue most frequently experienced by college students was anxiety and
stress over college-related expenses. (71.3%)14
Students have a number of aid options including federal, state and institutional grants;
guaranteed and non-guaranteed student loan programs; and work-study programs. The
Health Education Act of 1965 authorized three forms of federal aid, the Educational
Opportunity Grants (which latter became Pell Grants); Guarantee Student Loans (which
latter became Stafford Loans); and the College Work Study program. These programs
are known collectively as “Title IV aid”. The HOPE and Lifetime Learning tax credits were
added in 1996 to added tax credits to offset the tuition payments, and parents were
allowed to take out loans starting in 1992 (Heller 2014). States have also increased their
need-based and non-need-based grant programs. Roughly 30% of all state grants and
14
http://jobs.aol.com/articles/2012/08/13/top-6-reasons-older-college-students-drop-out/
55% of institutional grants are not based on need. Students in middle upper and upper
income groups take on non-secured debt form from private lenders (Heller, 2014).
While the average Pell Grant award increased to $4,500 in 2011, the actual purchasing
power of the award decreased to 32% from 33% of public 4 year tuition in 1976=77
(adjusted for inflation) (Dynarski and Scott-Clayton, 2014). Between 1979-80 and 200809 total federal grant expenditures increased 28% (to $24.8 billion) while student loan
borrowing increased 577% (to $84.0 billion/year) adjusted to 2008 dollars (Heller, 2014).
The total student loan debt crossed the $800 billion mark in 2010 (Avery and Turner,
2014). Forty-one percent of students in private 4-year universities and 54% of students
in private nonprofit 4-year universities accumulated student debt in 2007-08. While the
average debt load for undergraduates is about $25,000, students in private schools,
graduate school and professional programs accumulate more debt (Dynarski S and
Scott-Clayton, 2014).
Some have questioned if students are taking loans to finance a life-style rather than
financing their education. The three potential problems with large student debt load
are that 1) it may direct students to high-paying careers at the expense of lower-paying
jobs such as teaching; 2) if students don’t understand the loan repayment terms it can
compromise the financial solvency of graduates and impede future investments and
economic growth; 3) the value of the college education may not be worth the long-term
cost (Avery C and Turner S, 2014; Williams J, 2006).
Research on student aid programs over the past 59 years has revealed that aid programs
increase access to education; the complexity of the application process can be a
deterrent for some to access aid; adding academic incentives to aid, increases average
GPAs and may improve persistence; students/families may not understand the longterm implications of loan repayment when they take out the loans (Dynarski S and
Scott-Clayton, 2014).
Recommendation: Schools of Pharmacy should 1) continue to help students navigate
the financial aid process and utilize a variety of aid other than loans; 2) seek donations
for scholarships; and 3) provide student access to financial management programs to
enable them to manage debt and newly earned salaries.
5) Explore a rethinking of current curriculum models towards providing, flexible,
individualized competency-based programs consistent with development of
professional values of self-assessment and continual learning so students, the
profession and society can be assured all graduates have been adequately prepared by
having to meet competency assessments.
The types of higher education institutions and the delivery mechanisms have changed
over the past 50 years. Community colleges (i.e. 2-year institutions) accounted for 24%
of higher education enrollment in 1963 and 48% in 2009 ().15 With the current proposal
of free community college for everyone proposed by President Obama, one can envision
these enrollment figures to soar. Historically higher education was provided by public
non-profit or private non-profit institutions. By 2001 private for-profit organizations
had entered the market, accounting for 6% of the enrollment. Their market share
increased to 12% by 2011. While only accounting for 12% of enrollment, for-profit
institutions account for 21% of Pell Grant.16
The delivery of higher education varies widely from large lecture-based
freshman/sophomore courses taught by graduate students in large private and public
institutions to smaller classes at smaller institutions to a production model at large forprofit institutions were specialists design syllabi and course materials centrally that are
delivered locally by professionals in the field. (Baum, Kurose, and McPherson, 2013 and
ref 57). There has also been a shift from full-time tenure track faculty to non-tenuretrack and part-time and adjunct instructors. Instruction by full-time faculty dropped
from 80% in 1970 to 51.3% in 2007. The proportion of non-tenure-track faculty grew
from 18.6% in 1975 to 37.2% in 2007. In pharmacy, the introduction of the entry level
Doctor of Pharmacy degree has resulted in an increase proportion of non-tenure-track
clinical faculty (Baum, Kurose, and McPherson, 2013-ref 58). The impact of these
changes on the quality of education is not known.
Technology is changing the way education is delivered. Online and computer-assisted
instruction, as well as, interactive internet based connections such as Skype expand
access to education—no doubt making the content loop component more efficient.
The 2011-12 Argus Commission acknowledged disruptive innovation’s potential impact
on pharmacy education by recommending that technology be used “liberally” in giving
credit for prerequisite and professional school requirements by “permitting a more
flexible acquisition of knowledge and skills, both in the pre-pharmacy period and in the
professional program” but only if individualized, technology-based assessment tools
were available and used. Though disruptive to the traditional lock-step curriculum, it
would promote “creativity, life-long learning and ongoing self assessment of knowledge
and skills.” “An embracing of innovation by faculty and accreditors alike, as well as
students, would be essential to the implementation of such a disruptive innovation, but
the benefits could be very large.” 17
The current model of pharmacy education evolved over the years from purely
experiential to mostly didactic and now back towards center with approximately 1/3 of
the curriculum being experiential. Accreditation Standards have focused on curriculum
length and structure with two years foundational, pre-pharmacy-type coursework,
Baum, Kurose, and McPherson, 2013-ref 50
Baum, Kurose, and McPherson, 2013-ref 53-54
17 American Journal of Pharmaceutical Education 2012; 76 (6) Article S3, p7
15
16
followed by 2 or 3 years didactic professional coursework followed by one year of
experiential education.
In pharmacy, as in medical education, teaching models tend to rely on the lecture
format with a focus on quantitative testing methods, e.g., multiple choice exams, that
tend to promote and assess memorization rather than professional competencies. We
question whether that curricula and its teaching contribute to life-long learning and
continual self-assessment which are fundamental goals of professional education.
It is logical to organize coursework, based on level of content presented. Curriculum
cohorts progress in lock-step fashion, sequenced to build upon previous learning: basic
science foundation is need for their application in the clinical sciences with little
flexibility for progression. This is true regardless of whether the program is on campus
or distance. Successfully meeting expectations within courses yields a compilation of
credits that define the PharmD degree and, theoretically, professional competence.
The typical pharmacy curriculum is inflexible and teacher-centered. And, as with most
traditional classroom education, seat time and examinations determine progress
towards achievement of the program credential, i.e., the PharmD degree. Students who
are not successful in a prerequisite course in the sequence are held back from
continuing on with the original cohort. Students must attend full-time to remain on
track rather than progress at their own pace as when instruction is individualized.
Tangentially but related, no matter what the level of experience with which an incoming
student arrives, all in the cohort must take the same courses at the same rate of
completion allowing for little-to-no flexibility.
Recent micro-disruptions in this traditional process in pharmacy education include the
use of accelerated and distance, i.e., online, programs. To date, there are 14
accelerated programs, meaning professional students attend school year-round to
complete the 4-year curriculum in three, comprising a burden of carrying heavier course
loads with minimal breaks.18
Once the PharmD became the official entry –level degree, distance programs were and
still are successfully used for PharmD completion programs, using a combination of
online education and onsite experiential work. Creighton University first made use of
online education for a distance pathway program adding to its on campus program in
2001. Online or distance programs can be very affordable: travelling and costs are
diminished, automatically reducing overall costs. Students can also pursue full time
18
http://www.pharmdprograms.org/accelerated-pharmacy-schools/
work without having to worry about missing classes or lectures. It offers a very flexible
mode of getting qualifications at college level.19
Colleges of pharmacy traditionally have relied on and recruited from the college-age
cohort which is diminishing in many parts of the country resulting in a need and efforts
to accommodate diverse markets/populations, e.g., recruiting from working adults with
previous degrees who wish a career change. Typically, there are four barriers to further
education for working adults: the lack of time to pursue education; family
responsibilities; scheduling of course time and place; and the cost of educational
courses.20 Programs that can easily address some of these issues will open up
opportunities to this group, thus promoting some level of access and affordability. New
curricular/program models are evolving to become more accessible, cost-efficient, and
for some, accountable.
The notion of “Flexible learning” is “accessing education in a way that is responsive in
pace, place and/or mode of delivery. It is often supported by the use of credit
accumulation and transfer.”21 Flexible learning can include the use of technology to
provide remote or online study, part-time learning, accelerated or decelerated
programs and distance or blended learning. It can help meet the needs of a diverse
range of students, enable part-time study that could be attractive for current and/or
future pharmacy employers, allow students to combine work, study and family, and
enable students to develop skills and attributes to successfully take control of learning
goal-setting in order to adapt to change in their future practice of pharmacy.
More specifically, flexible learning is defined in terms of offering students choice in the
pace, place and mode of learning.22 “Pace” includes accelerated and decelerated
programs, part-time learning, recognition of prior learning and the associated use of
credit frameworks. “Place” is the primary domain of learning which is Colleges/schools
of pharmacy but can include work-based learning and private or consortium-based
providers of coursework. Technology-enhanced learning enables flexibility of learning
across geographical boundaries. Finally, “mode” focuses on the role of learning
technologies in enhancing flexibility, e.g., distance learning, blended learning,
synchronous and a-synchronous modes of learning.
With too little flexibility, programs may lack the capacities adequately to respond to a
changing enrollment market environment and market make up. Programs with too
much flexibility may run the risk of lacking integrity and a lowering of standards. The
1919
http://www.excite.com/education/healthcare/pharmacy#what-can-i-learn-in-online-pharmacyprograms-us
20 Cahalan, M., Lacireno-Paquet, N., & Silva, T. (1998). Adult education participation decisions and
barriers: Review of conceptual frameworks and empirical studies. Washington, DC: U.S. Department
of Education, Office of Education Research and Development, National Center for Education Statistics.
21
22
https://www.heacademy.ac.uk/workstreams-research/themes/flexible-learning
https://www.heacademy.ac.uk/sites/default/files/resources/FL_summit_report_final.pdf
inclusion of competency-based education (CBE) would provide some assurance of
integrity with the use of common competencies advocated by ACPE. Accreditation goals
are to assure minimum competencies and some level of standardization among
schools/colleges of pharmacy.
Figure 1 presents common terminology and conceptual relationships for competencybased education proposed by the Department of Education. The figure does not
address different models that can lead to the top of the hierarchy. Reliable and valid
assessments are paramount to operationalizing the model.
Figure 1. Hierarchy of Outcomes
Department of Education, 200123
Porter and Reilly discuss three competency-based curricular models that have the
potential to maximize resources for student success:24
1. Traditional course- credit-based with alternative assessments, e.g., portfolios,
instead of exams(Alverno).
Traditional credit-based courses with traditional assessments—whether in-seat
(traditional cohort/modular) or online—have been the stalwart of typical college
assessment, including colleges of pharmacy. Though the two most recent
iterations of ACPE accreditation standards have advocated for the use of student
portfolios, portfolios use has been complementary to traditional assessment
23
US Department of Education, National Center for Education Statistics. Defining and Assessing Learning: Exploring
Competency-Based Initiatives,Washington, DC: 2001.
24 Competency-Based Education as a Potential Strategy to Increase Learning and Lower Costs Stephen R. Porter &
Kevin Reilly
methods. Student portfolios can be a “useful tool in assessing student
progression and achievement of educational competencies”25; however, no
standard definition or standard approach has been advocated or developed by
the Academy for their use which has resulted in limited implementation.
2. Prior learning assessment (PLA): recognition that advances students towards
degree completion (course credits or competencies)
Formal Recognition of Prior Learning (RPL) is an assessment process aimed at
confirming and recognizing the competencies a candidate has obtained outside
of a formal education and training environment. These competencies might have
been gained through informal or non-formal training, such as MOOCs or badge
systems, or they may have been gained through life or work experience.26 This
recognition can be used:
 as an alternative mechanism for gaining access to a course or qualification:
matriculating students may gain entry to a course or qualification using RPL
as an alternative to possessing the prerequisites for pre-requisite-based
entry. For example, an applicant, having received “credit” from taking MOOC
course in economics could be exempt from that prerequisites after meeting
certain qualifications.
 for the award of unit/s of competency that form part of a qualification,
leading to the partial or full completion of the requirements for that course.
A person working in a hospital or community pharmacy might have select
skills that do not need to be taught but rather demonstrated, e.g., IV
admixture, prescription-filling, and be exempt from participating in a section
of a course.
3. Progress through mastery of competencies, taking as little or as much time as
needed (Western Governors, Southern NH, UWisconsin system) to master the
competency.
There are variations in Competency-based Education (CBE) models. The coursebased model links student progress traditionally measured by seat time in direct
instruction. In this model, program competencies are translated into topics to be
included into courses. The same material is covered in the CBE assessment as
expected in a course in the discipline. Theoretically, students can proceed at
their own pace and accelerate time to degree in programs that are typically
online. The other, direct assessment based model is not directly linked to specific
course material, seat time, and the credit hour. In this model, learners
demonstrate mastery of the competencies at their own pace, typically online,
Portfolio Use and Practices in US Colleges and Schools of Pharmacy, Skrabal et al., AJPE 2012; 76
(3) Article 46, p. 7
26 Recognition of Prior Learning: An assessment resource for VET practitioners [2nd ed.] Department
of Education and Training, 2008
25
and progress through academic programs when they are ready to do so. 4 The
direct-assessment model is the ultimate student-centered, flexible curriculum
which leads to better student success and engagement and promotes the notion
of self-directed learning via self-assessment and continual learning necessary for
continual professional development (CPD).. “ACPE defines CPD as a “selfdirected, ongoing, systematic and outcomes-focused approach to lifelong
learning that is applied into practice [which] involves the process of active
participation in formal and informal learning activities that assists individuals in
developing and maintaining continuing competence, enhancing their
professional practice, and supporting achievement of their career goals.” 27
Competency-based education also can … “make better use of technology, support new staffing
patterns that utilize teacher skills and interests differently, take advantage of learning
opportunities outside of school hours and walls, and help identify opportunities to target
interventions to meet the specific learning needs of students. Each of these presents an
opportunity to achieve greater efficiency and increase productivity.”28
With the use of technology, data is available monitor student progress, requiring the
development and use of a specific learning management system, such as the College for
America’s CfA Learning Environment, to monitor progress and intervene as needed.29
For competency based education to be effective and transparent, we must articulate
what constitutes the PharmD credential and the curricular architecture framework that
communicates what graduates will be able to do upon graduation with the degree.
Shared competency statements as espoused by ACPE can facilitate transferability
between programs. From these competencies, sub-competencies, criteria and
assessments can be developed.30
Additional resources or reallocation of resources are needed for successful programs.
Faculty role is unbundled, i.e., not the sole source of curriculum content and design.
Rather, faculty define the competencies, assure understanding via design and provision
of oversight of formative and summative assessments. In direct-assessment models,
students require a coach to guide the student throughout the program. Tutors may be
needed to assist students by providing additional subject matter support once
assessment feedback is received. Additional whole-person student support, e.g.,
financial aid, career counseling, help students succeed in these types of programs.
These changes likely will necessitate redefined business models, requiring significant
human resource and monetary commitments.
Pharmacy Education has been spurred toward competency based education with the
new ACPE Standards 2016. These standards were developed with input from various
27
https://www.acpe-accredit.org/ceproviders/CPD.asp
28
http://www.ed.gov/oii-news/competency-based-learning-or-personalized-learning
29
Jodi Lewis, EDUCAUSE 2014, Nextgenlearning.org “CfA Learning Environment (CLE)”
30
Investing in Quality Competency-based Education (Educause Review) EDUCAUSE.edu.
professional sources, including the AACP CAPE Outcomes, the Institute of Medicine
(IOM) description of competencies that all healthcare professionals should attain during
their education, The Joint Commission of Pharmacy Practitioners’ (JCPP) Vision of
Pharmacy Practice released in 2013 and “Pharmacists’ Patient Care Process”, developed
by a work group from 11 national pharmacy organizations and endorsed by the Joint
Commission of Pharmacy Practitioners in 2014.31
Medical Education has begun to explore new competency-based paradigms for
professional education. In Educating Physicians: A call for Reform of Medical School and
Residency, recommendations include standardizing learning outcomes through
assessment of competencies; individualizing the learning process, allowing opportunity
to progress within/across levels when competencies are achieved; and, offering elective
programs to support the development of skills for inquiry and improvement. This way,
high standards can be achieved while allowing greater flexibility in the learning process,
possibly shortening the educational process when competence is achieved early.32 One
Competency-Based Medical Education example is TRANSFORMATION IN MEDICAL
EDUCATION (TIME), a multi-institutional initiative in the University of Texas System.
CBE can address the tri-partite goals of access, affordability and accountability:
institutions can become more accessible to non-traditional students and accountable to
society with opportunities to accelerate or decelerate curricula for all.
Misc:
A SABER model for taking a systems approach to developing educational policy may be
worth investigating by AACP and Colleges of Pharmacy.
Degree qualifications Profile using the”Bologna Process” approach: Associate level (Prepharm or technician); BS level and PharmD level.
31
https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf
32
Educating Physicians: A call for Reform of Medical School and Residency