From Technical Evaluation to Educational Alliance: Stakeholder Perspectives on Medical School Accreditation in Korea

From Technical Evaluation to Educational Alliance: Stakeholder Perspectives on Medical School Accreditation in Korea | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Technical Evaluation to Educational Alliance: Stakeholder Perspectives on Medical School Accreditation in Korea Ye Ji Kang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6575482/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Accreditation plays a critical role in ensuring educational quality and institutional accountability. In South Korea, a centralized accreditation system for medical schools has been in place for over two decades. While the adoption of updated national standards in 2019 aligned the system with international accreditation frameworks, little is known about how diverse stakeholders perceive and engage with these evolving standards in practice. This study aims to explore how stakeholders involved in Korean medical education interpret, navigate, and respond to the accreditation process, with a particular focus on relational dynamics and institutional trust. Methods: A qualitative design was employed using 18 focus group discussions (FGDs) with 53 participants, including self-evaluation committee members, site visit evaluators, staff from the national medical education accreditation body, and medical students. Data were analyzed inductively through content analysis using MAXQDA, following the COREQ guidelines. Results: Five major themes were identified: (1) strategic compliance versus authentic quality improvement, (2) institutional disparities and resource dependency, (3) evaluator conduct and the credibility of outcomes, (4) asymmetries in trust and communication, and (5) cyclical reform fatigue. Notably, participants emphasized the demeanor and interpersonal conduct of evaluators as critical to the perceived fairness and impact of the accreditation process—highlighting the importance of relational factors in an often standardized system. Conclusions: This study empirically extends the concept of an "educational alliance"—a model previously introduced in the literature that reconceptualizes accreditation not merely as periodic assessment, but as a relational, collaborative, and trust-based process aimed at meaningful educational improvement. By foregrounding mutual understanding, contextual responsiveness, and relational accountability, the educational alliance model offers a more sustainable and meaningful approach to quality improvement in medical education. These findings offer timely insights for accreditation reform in Korea and other health professions education systems navigating similar tensions. Medical School Accreditation Qualitative Research Educational Alliance Stakeholder Perspectives INTRODUCTION The Korean accreditation system began as a voluntary initiative but gradually evolved into a government-recognized mechanism for ensuring educational quality and institutional accountability. This shift—from the Accreditation Board for Medical Education in Korea (ABMEK) to the formal establishment of KIMEE (the Korean Institute of Medical Education and Evaluation)—was largely driven by growing concerns within the medical community about the unchecked expansion of medical schools and declining educational standards [ 1 ]. With the introduction of the ASK 2019 standards (Accreditation Standards of KIMEE), which have been recognized by the World Federation for Medical Education (WFME), Korea’s accreditation framework has since moved toward greater alignment with global norms and expectations [ 1 , 4 ]. ASK 2019, the latest accreditation standard adopted in Korea, reflects a shift toward student-centered and performance-based medical education, emphasizing integrated curricula and aligning with both national needs and international trends [ 5 ]. However, the implementation of these standards has surfaced multiple tensions. While the educational field is shifting toward outcome-based and competency-oriented medical education, accreditation systems are expected to support and assess this transformation without uniformly adequate institutional capacity [ 3 , 4 ]. As a result, institutions often experience strain in adapting to evolving expectations under resource and contextual constraints. Existing literature on medical education accreditation has primarily focused on the policy evolution of the KIMEE framework and alignment with global standards [ 1 , 2 ]. Yet, there remains a lack of qualitative insight into how diverse stakeholders—including faculty, administrators, evaluators, and students—actually experience the accreditation process under ASK 2019. Research is needed to understand how stakeholders interpret the values embedded in accreditation, respond to its demands, and assess its contribution to educational quality and institutional development [ 6 , 7 ]. Furthermore, while accreditation is conventionally characterized as a standardized and technically driven process, a growing body of academic literature has emphasized its inherently relational and interpretive nature. While conceptual papers have increasingly drawn attention to how factors such as the demeanor and professionalism of evaluators, the quality of communication between evaluators and institutions, institutional perceptions of fairness, and the degree of mutual trust may shape how accreditation procedures are implemented and experienced in practice [ 8 ], empirical research in this area remains limited—particularly in the Korean context. This study seeks to address these gaps by exploring the perspectives and experiences of key stakeholders involved in medical school accreditation in Korea. Drawing on focus group discussions (FGDs) with self-evaluation committee members, visiting evaluators, KIMEE staff, and medical students, the study examines how accreditation is understood, negotiated, and enacted in practice. Based on these findings, it engages with the concept of an "educational alliance"—a model that reconceptualizes accreditation not merely as a periodic assessment exercise, but as a relational, collaborative, and trust-based process oriented toward meaningful and sustainable educational improvement. While this concept has previously been introduced in global literature by Telio et al. (2015) [ 9 ] and more contextually in the Korean accreditation landscape by Jung et al. (2020) [ 8 ], this study empirically extends and substantiates the educational alliance framework by grounding it in the lived experiences of stakeholders navigating the contemporary ASK 2019 cycle. METHODS Study Design This qualitative study was designed to explore how key stakeholders involved in Korea’s medical education accreditation process interpret, engage with, and respond to the standards and procedures associated with ASK 2019. The study employed focus group discussions (FGDs) to capture a range of perspectives within and across stakeholder groups. Participants and Sampling Using purposeful sampling [10,11], we recruited 53 participants across four stakeholder groups: (1) self-evaluation committee members from 40 medical schools, (2) visiting evaluators with experience in accreditation site visits, (3) administrative staff affiliated with the medical education accreditation body, and (4) medical students who participated in accreditation-related activities. Selection criteria included direct experience with accreditation processes and willingness to participate in group dialogue. Participants were identified through institutional contacts, official invitations, and referrals from accreditation authorities and medical school administrators (Table 1). [Insert Table 1 here] Data Collection Between December 2022 and January 2023, a total of 18 FGDs were conducted, ranging from 2 to 4 participants per group. Interviews were facilitated in either in-person or virtual formats depending on participant availability and geographic location. Discussions were guided by a semi-structured protocol organized around three domains: (1) perceptions and meanings of accreditation, (2) experiences with preparing for and participating in accreditation, and (3) suggestions for improvement. All sessions were audio-recorded with consent and transcribed verbatim. Ethics approval and consent to participate This study was approved by the Institutional Review Board of a university in South Korea (Approval No. HYUIRB-202307-011). All participants signed an informed consent form prior to participation. Participation was voluntary, and participants were informed of their right to withdraw from the study at any time without consequence. Confidentiality and anonymity of their responses were fully guaranteed. Data Analysis and Validity Evaluation This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [12]. The collected data were analyzed using qualitative content analysis [13]. As a first step, the researcher listened to the audio recordings multiple times to become familiar with the participants and their narratives. The transcripts were then reviewed to extract relevant statements, which were grouped into initial units of meaning based on recurring ideas and implied meanings. The analysis then proceeded with categorizing these units into broader categories when thematic similarities were identified. Subsequently, overarching themes were derived that encompassed multiple categories and reflected shared patterns across stakeholder groups. To support this process, MAXQDA20 (VERBI GmbH, Berlin, Germany, 2019) was used to organize and code the data efficiently. In addition to peer debriefing and member checking, the researcher engaged in reflexive journaling throughout the data collection and analysis phases. This included documenting personal assumptions, expectations, and emotional responses to participant narratives, with the aim of increasing awareness of potential biases. Reflexivity was particularly critical given the researcher’s background in medical education and familiarity with the accreditation system. To mitigate interpretive bias, the researcher revisited the coding framework iteratively, sought alternative interpretations of ambiguous data, and critically examined how their positionality may have shaped the thematic structure. Through these reflexive practices, the researcher aimed to enhance the confirmability and credibility of the findings. As a common qualitative research technique, direct quotations from participants were included to illustrate key findings and preserve the richness of stakeholder perspectives. Quotations were selected based on their representativeness and clarity in conveying the theme. However, due to methodological constraints, not all participant narratives could be included. To further ensure trustworthiness, the researcher regularly engaged in peer debriefing with colleagues familiar with the research context and shared preliminary findings with selected participants to verify the accuracy and authenticity of interpretations [14]. RESULTS Thematic analysis of the focus group discussions yielded five major themes that captured the complex and multifaceted nature of accreditation experiences among Korean medical education stakeholders. These themes reflect both systemic challenges and relational tensions embedded within the accreditation process. Table 2 presents the main theme and representative subthemes. [Insert Table 2 here] Strategic Compliance vs. Authentic Quality Improvement Stakeholders broadly acknowledged that medical education accreditation played a pivotal role in prompting institutional change and elevating educational standards. Many emphasized that accreditation was instrumental in ensuring the basic qualifications and infrastructure of medical education, and even served as a catalyst for institutional investment and recognition: “Accreditation has led to significant budget investments, which in turn has contributed to the university’s substantial development. Especially, the increased interest from foundations and stakeholders toward the university due to accreditation cannot be ignored.” (Self-Evaluation Committee 10, FGI 4) Moreover, the process encouraged internal discussions around quality assurance and fostered a culture that increasingly values continuous improvement: “Without accreditation, we would have been like ‘a big fish in a small pond,’ unaware of the situations in other medical schools. It has provided us with insights into areas that need continuous quality improvement and has fostered a culture emphasizing the importance of ongoing enhancement.” (Self-Evaluation Committee 11, FGI 4) Nevertheless, participants also expressed concern that the process sometimes led to performative compliance rather than genuine transformation. Several described a sense of "checklist fatigue" where the emphasis shifted from educational reflection to fulfilling formal requirements: “We know what to write and what they want to hear. It’s less about our identity as a school and more about aligning with templates.” (Self-Evaluation Committee, FGD 10) Despite these limitations, many still regarded accreditation as a useful tool to initiate otherwise difficult conversations within institutions and align stakeholders around shared goals: “I firmly believe that accreditation has indeed contributed to the improvement of the medical school’s quality. Especially when trying to reach a consensus among school members… when I mention that ‘it is part of the medical education accreditation standards,’ they become quiet.” (Self-Evaluation Committee 9, FGI 3) Institutional Disparities and Resource Dependency Focus group discussions highlighted considerable disparities in accreditation readiness among institutions. Resource constraints—whether in faculty numbers, funding, or administrative support—impacted schools’ ability to prepare effectively. Several smaller schools shared that preparing for accreditation often competed with core teaching and clinical responsibilities: “We don’t have the luxury to talk about innovation—we’re just trying to survive the paperwork.” (Self-Evaluation Committee 21, FGD 7) “Unlike large universities with dedicated educational staff, our team is all clinical faculty with heavy schedules. It’s almost impossible to manage both.” (Self-Evaluation Committee 23, FGD 8) The presence—or absence—of medical education experts significantly shaped how schools approached accreditation. Institutions with internal expertise were able to conduct faculty development sessions and interpret ASK 2019 standards with more confidence: “Our university has the capacity to conduct internal workshops because we have KIMEE representatives who have experience as visiting evaluators.” (Self-Evaluation Committee 7, FGI 3) Others, however, relied heavily on KIMEE-led external workshops and faced challenges in localizing the standards to their own contexts: “We tend to rely solely on external workshops organized by KIMEE as we lack human resources to conduct our own training.” (Self-Evaluation Committee 9, FGI 3) Evaluator Conduct and the Credibility of Outcomes Participants widely recognized the importance of evaluator professionalism in shaping the legitimacy and emotional tone of the accreditation process. While several participants noted positive experiences: “One evaluator told us our efforts were visible and appreciated. That changed the entire team’s morale.” (Self-Evaluation Committee 13, FGD 5) Others recalled less constructive interactions: “In one case, an evaluator corrected a faculty member mid-sentence in a demeaning tone. That kind of interaction shuts down honest communication.” (Self-Evaluation Committee 16, FGD 6) Evaluator expertise was also seen as crucial. Participants expected evaluators not only to apply standards consistently, but also to contextualize them based on a school’s mission and resources: “At times, it felt as though our school’s smaller size led to assumptions about our performance, with limited recognition of our unique mission and context.” (Self-Evaluation Committee 1, FGD 1) Despite concerns raised by self-evaluation committee members regarding evaluator conduct and perceived inconsistencies, visiting evaluators offered a contrasting perspective. Many of them acknowledged KIMEE’s sustained efforts to improve evaluator professionalism and consistency through structured development programs. These included inter-rater reliability workshops, team leader training, and frequent deliberative meetings during the evaluation process itself. Such efforts were seen as valuable for calibrating standards and fostering shared understanding among evaluators. “It was quite satisfactory to have all area-specific committee meetings gather together. These meetings help. I believe that enhancing the understanding of accreditation standards and improving evaluation expertise can be achieved prior to the visiting evaluation.” (Visiting Evaluator 2, FGI 1) Asymmetries in Trust and Communication Several participants described interactions with evaluators and KIMEE as overly formal, hierarchical, and time-constrained. This hindered opportunities for mutual understanding and knowledge exchange: “We want feedback that feels like dialogue, not judgment. Right now, it’s more of a one-way street.” (KIMEE Staff 3, FGD 1) “There was no chance to ask questions back or explain why certain decisions were made. It felt like we were being talked at, not with.” (Self-Evaluation Committee 14, FGD 5) Time pressure was especially felt during site visits, which often lacked space for schools to introduce themselves and build rapport. Participants recommended longer visits or structured pre-visit engagements to foster relational trust. Cyclical Reform Fatigue and Accountability Dilution Although stakeholders recognized that accreditation can drive continuous improvement, they also voiced concerns about reform fatigue. The repetitive nature of documentation, leadership turnover, and short institutional memory diminished the impact of post-accreditation improvement plans: “Improvement reports are just words on paper. By the time the next cycle comes, no one remembers what was promised.” (Self-Evaluation Committee 35, FGD 12) “Those who write the reports and those who implement them are rarely the same people. It’s like sending a message into the void.” (Self-Evaluation Committee 31, FGD 11) Nevertheless, for some research participants—particularly visiting evaluators—accreditation work was viewed as a valuable learning experience and a chance to grow professionally in the field of medical education: “I could learn about a new field and felt really satisfied with the process… undergoing reviewer committee’s scrutiny allowed us to improve our report writing skills.” (Visiting Evaluator 2, FGI 1) Perceptions of accreditation varied significantly between stakeholder groups. While many self-evaluation committee members described the process as burdensome and repetitive, some visiting evaluators reflected on it as an opportunity for professional growth and deeper insight into educational practices. These contrasting experiences illustrate how accreditation can be interpreted differently depending on one's role and proximity to institutional constraints. DISCUSSION This study illuminates the nuanced and multi-dimensional experiences of stakeholders engaged in the Korean medical education accreditation process. While accreditation has long served as a mechanism for quality assurance and institutional accountability, our findings highlight that its implementation is shaped not only by formal standards but also by relational dynamics, institutional capacity, and the interpretive practices of those involved. These insights challenge the assumption that accreditation is merely a technical or standardized procedure, suggesting instead that it is negotiated at the intersection of shared ideals and practical constraints. First, while accreditation was broadly recognized as a catalyst for institutional development, many participants described a tension between strategic compliance and authentic quality improvement. While the process prompted significant investments and encouraged internal dialogue around educational standards, it also generated fatigue due to repetitive documentation and a checklist-oriented culture. Nonetheless, some participants viewed accreditation as an opportunity to legitimize educational conversations and foster a culture of continuous improvement. Accreditation, in this view, functioned not only as an external requirement but also as a vehicle for internal mobilization and collective responsibility. Second, participants emphasized persistent disparities in institutional resources, which posed challenges to equitable engagement with the accreditation process. Schools with limited human or financial capacity, or without in-house medical education expertise, often found it difficult to meet expectations and relied heavily on external workshops. In contrast, institutions with internal accreditation experts were able to conduct faculty training and align standards with local development efforts. These differences highlight the need for accreditation policies that accommodate institutional diversity and provide differentiated support mechanisms. For example, while some schools have faculty members with extensive accreditation experience or dedicated educational staff capable of conducting internal training and interpreting standards independently, others lack such personnel and face considerable limitations in administrative or financial capacity. These disparities suggest that the uniform application of standards may inadvertently reproduce structural inequities and undermine the credibility and fairness of the accreditation process. Therefore, accrediting bodies should consider context-sensitive policy adaptations—such as extending pre-visit consultation opportunities for resource-limited schools, offering flexible timelines for site visits, providing annotated guides with case-based interpretations of standards, and supporting post-visit improvement planning through institutional coaching or mentoring. Such differentiated approaches can enhance not only procedural fairness but also the substantive legitimacy and sustainability of the accreditation system. Third, the demeanor, expertise, and communicative conduct of evaluators emerged as crucial to the perceived fairness and impact of accreditation. Participants valued evaluators who not only understood the standards but were also able to contextualize them based on the unique missions, histories, and constraints of individual schools. Mutual respect, empathy, and clarity of communication were repeatedly cited as key to creating a positive and productive evaluation experience. These findings reinforce the idea that the perceived legitimacy and trustworthiness of accreditation depend not only on the consistent application of standards, but also on the quality of interpersonal interactions between evaluators and institutions. Specifically, how evaluation is communicated—whether evaluators demonstrate respect, contextual awareness, and empathetic dialogue—plays a central role in how accreditation is received and interpreted by stakeholders. This resonates strongly with the concept of relational accountability, which emphasizes that evaluative legitimacy is shaped as much by human relationships as by procedural rigor. In this study, institutions reported higher levels of trust and acceptance of accreditation outcomes when evaluators listened attentively, acknowledged institutional missions, and provided respectful, constructive feedback. These encounters often led to greater internal engagement with quality improvement. In contrast, when feedback was delivered in a rigid, dismissive, or context-blind manner, participants described experiencing distrust, defensiveness, and skepticism about the fairness of the entire process. These examples illustrate that for accreditation to be perceived as credible, it must be not only technically sound but also relationally sensitive in its delivery and interpretation. Fourth, asymmetries in communication and limited opportunities for mutual exchange were identified as ongoing challenges. While participants appreciated the role of accreditation in prompting conversations about quality, they also expressed frustration with the lack of dialogic engagement during and after site visits. Many suggested establishing more iterative and interactive communication mechanisms—before, during, and after evaluations—to ensure shared understanding and reduce misinterpretation. Such changes could help shift the process from a one-directional assessment model to a more collaborative and relational form of engagement. Finally, the study sheds light on reform fatigue. Although accreditation cycles were designed to promote continuous quality improvement, stakeholders reported that improvement plans were often symbolic and inconsistently implemented. Leadership turnover, the erosion of institutional memory, and a structural disconnect between planning and implementation contributed to this fatigue. This dual burden of quality enhancement and administrative overload reflects the findings of Blouin et al. (2018), who observed that while accreditation fosters quality-oriented processes, it also generates negative consequences for faculty morale, innovation, and institutional efficiency [2]. These concerns are consistent with previous findings suggesting that cyclical accreditation processes can lead to fatigue and diminish intrinsic motivation for sustained reform, while also fostering a “checklist mentality” that favors formal compliance over genuine innovation [3]. As highlighted in broader literature on educational reform, maintaining institutional memory through leadership continuity and internal capacity-building remains essential for long-term improvement [15]. At the same time, some participants found the process personally meaningful, citing opportunities for professional development and greater insight into educational practice. This duality—between fatigue and formative value—highlights the need for accreditation systems that not only enforce standards but also support growth and learning. Stakeholders simultaneously experienced accreditation as a repetitive and burdensome obligation—marked by administrative overload and uncertainty—yet also as a meaningful opportunity for institutional reflection, collaborative dialogue, and educational development. This tension suggests that how accreditation is designed and delivered can significantly shape whether it is perceived as punitive or developmental. Taken together, these findings support a reconceptualization of accreditation not merely as a compliance mechanism but as a form of educational alliance—a trust-based partnership between institutions and evaluators [7,9]. This framework emphasizes mutual understanding, co-construction of meaning, and sustainable quality improvement through ongoing dialogue [9]. From this perspective, accreditation is not simply a standardized or technical process; rather, it is a negotiated practice situated at the intersection of shared educational ideals and institutional constraints. By moving beyond procedural adherence and incorporating relational and contextual dimensions into evaluation systems, accreditation can evolve into a more credible, equitable, and meaningful driver of educational quality. CONCLUSION This study has explored the perspectives and experiences of key stakeholders involved in medical education accreditation in South Korea. Drawing on insights from a broad range of institutional voices, we find that accreditation is experienced not merely as a procedural or evaluative mechanism, but as a complex and relational process situated within the realities of institutional capacity, resource disparities, and evolving cultural expectations. One of the most salient findings is that the perceived effectiveness and legitimacy of accreditation depend not only on 'what is evaluated', but on 'how evaluation is conducted'. Evaluators, positioned as both assessors and communicators, play a pivotal role in shaping trust, morale, and institutional engagement. At the same time, structural challenges—including limited time for interaction, asymmetrical communication, and inconsistent follow-through—undermine the sustainability and credibility of the process. In response to these dynamics, we propose the framework of an educational alliance as both a conceptual and practical alternative to traditional accreditation paradigms. This alliance is grounded in mutual trust, reciprocal dialogue, shared purpose, and contextual responsiveness. It reframes accreditation from a one-way evaluative act into a collaborative and evolving partnership that supports institutional growth, reflection, and long-term improvement. Our findings suggest that stakeholders are not only open to such a shift—they are actively seeking it. They call for evaluation systems that are more dialogic than directive, more adaptive than rigid, and more supportive than punitive. By situating accreditation within the framework of an educational alliance, we invite a rethinking of the purpose and practice of accreditation. This reconfiguration offers a pathway toward more transparent, inclusive, and sustainable evaluation systems—ones that bridge the gap between policy and practice, accountability and capacity, evaluation and education. While grounded in the Korean context, this framework may also offer valuable insights for global efforts to redesign accreditation in ways that prioritize relational trust, institutional learning, and meaningful quality enhancement. Abbreviations ASK 2019 Accreditation Standards of the Korean Institute of Medical Education and Evaluation (2019) FGD Focus Group Discussion KIMEE Korean Institute of Medical Education and Evaluation WFME World Federation for Medical Education Declarations Acknowledgement The author sincerely thanks all participants in the focus group discussions—including self-evaluation committee members, accreditation site visit evaluators, KIMEE staff, and medical students—for their invaluable insights and contributions to this study. Authors’ contributions YJK conceptualized the study, conducted data curation and formal analysis, developed the methodology, and performed validation. YJK also wrote the original draft and reviewed and edited the final manuscript. The author read and approved the final manuscript. Consent for publication Not applicable. Availability of data and materials The datasets for this article are available from the corresponding author upon reasonable request. Competing interests The author declares that there are no competing interests. Funding This work was supported by INHA UNIVERSITY Research Grant. ORCID iDs Ye Ji Kang https://orcid.org/0000-0003-1711-2394 References Meng KH. History of the medical education accreditation system in Korea: Implementation and activities in the early stages. J Educ Eval Health Prof. 2020;17:29. https://doi.org/10.3352/jeehp.2020.17.29 Blouin D, Tekian A, Kamin C, Harris IB. The impact of accreditation on medical schools’ processes. Med Educ . 2018;52(2):182–91. https://doi.org/10.1111/medu.13471 Taber S, Leithead C, Naidoo K, Pilapil M, Battista R. A “fit for purpose” framework for medical education accreditation system design. BMC Med Educ . 2020;20:8. https://doi.org/10.1186/s12909-019-1912-z Yoo HH, Kim MK, Yoon YS, Lee KM, Lee JH, Hong SJ, et al. Changes in the accreditation standards of medical schools by the Korean Institute of Medical Education and Evaluation from 2000 to 2019. J Educ Eval Health Prof . 2020;17:2. https://doi.org/10.3352/jeehp.2020.17.2 Lim KY. A proposal for the future of medical education accreditation in Korea. J Educ Eval Health Prof. 2020;17:32. https://doi.org/10.3352/jeehp.2020.17.32 Korean Institute of Medical Education and Evaluation (KIMEE), Korean Institute of Medical Education and Evaluation. 20 years of footsteps of KIMEE. In: Proceedings of the symposium on the 20th anniversary of medical education accreditation: Past, present, and future of KIMEE (Brochure) (Nov 8). Seoul, Korea; 2019. Jung H, Jeon WT, An S. Is the accreditation in medical education an opportunity or a burden? Korean Med Educ Rev . 2020;22(1):16–27. https://doi.org/10.17496/kmer.2020.22.1.16 Chae SJ. Exploration of Development Tasks of Medical Education Accrediation Trhough In-dept Interviews. J of Humanities and Social Sciences 21 2021; 12(5):1605-1616. Telio S, Ajjawi R, Regehr G. The “educational alliance” as a framework for reconceptualizing feedback in medical education. Acad Med . 2015;90(5):609–14. https://doi.org/10.1097/ACM.0000000000000585 Merriam SB, Tisdell EJ. Qualitative research: A guide to design and implementation. Hoboken, NJ: John Wiley & Sons; 2015. Powell RA, Single HM. Focus groups. Int J Qual Health Care . 1996;8(5):499–504. https://doi.org/10.1093/intqhc/8.5.499 O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med . 2014;89(9):1245–51. https://doi.org/10.1097/ACM.0000000000000388 Krippendorff K. Content analysis: An introduction to its methodology. Thousand Oaks, CA: Sage Publications; 2018. Lincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks, CA: Sage Publications; 1985. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teach . 2010;32(8):638–45. https://doi.org/10.3109/0142159X.2010.501190 Tables Table 1. Details of stakeholder recruitment Stakeholder group Number of Participants Number of FGDs Recruitment details Self-evaluation committee members 40 14 ● One representative professor from each of the 40 medical schools in Korea. ● All have participated in at least two medical school accreditation cycles and possess expertise in medical education and evaluation. Visiting evaluators 7 2 ● Are seven members of the medical school accreditation site visit team (one representative from each committee at the Korean Institute of Medical Education and Evaluation). ● Have expertise in ASK 2019 accreditation standards and have participated in at least one site visit. They are familiar with the evaluation process and criteria. Staff members 3 1 ● Are current employees of KIMEE ● Have a high level of understanding in all aspects of the medical education accreditation process, serving as practical support for the accreditation. Medical school students 3 1 ● Have participated in accreditation activities, such as writing student reports or taking part in student interviews. Table 2. Theme and Representative Subthemes Theme Representative Subthemes 1. Strategic Compliance vs. Authentic Quality Improvement Checklist mentality, short-term focus, leadership discontinuity 2. Institutional Disparities and Resource Dependency Human/material constraints, external reliance, inequity in readiness 3. Evaluator Conduct and the Credibility of Outcomes Relational tone, evaluator attitude, contextual insensitivity 4. Asymmetries in Trust and Communication One-way feedback, time-limited interaction, miscommunication risk 5. Reform Fatigue and Accountability Dilution Symbolic improvement reports, low follow-through, organizational memory loss due to leadership rotation Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 15 May, 2025 Editor assigned by journal 14 May, 2025 Submission checks completed at journal 14 May, 2025 First submitted to journal 02 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6575482","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":450883828,"identity":"7b598b6a-c637-47dc-ace4-fdd38dfbd398","order_by":0,"name":"Ye Ji Kang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYHCChIMNQJKfmYENwuchVotkMwlaGBhBWgwOEKvF4HjDw4Mzau7YbT7Oe+zBDwY7eQaesw/wazlzIOHghmPPkrcd5ks37GFINmzgbTfAr+VGQsLBB2yHk80O85hJ8DAwJzDwsxFw2P0HQC3/DicbN/OYSf5hqCdCyw1giG1sO2xnwMxjJs3DcDiBgbcNvxbJM0CHzew7nCABdJi0jMFxwzaeY/i18B0/k/yx59the/7+M2aSbyqq5fl50vBrUTjAkwCiExsg7mRgIOATBgb5BvYDINqekMJRMApGwSgYwQAAo/1HqtPxIjsAAAAASUVORK5CYII=","orcid":"","institution":"Inha University","correspondingAuthor":true,"prefix":"","firstName":"Ye","middleName":"Ji","lastName":"Kang","suffix":""}],"badges":[],"createdAt":"2025-05-02 05:08:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6575482/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6575482/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81960351,"identity":"32aca541-4295-4881-a97f-14f988db192b","added_by":"auto","created_at":"2025-05-05 10:40:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":477858,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6575482/v1/f1756b73-6f61-41c2-9f9a-0291d340304f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Technical Evaluation to Educational Alliance: Stakeholder Perspectives on Medical School Accreditation in Korea","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe Korean accreditation system began as a voluntary initiative but gradually evolved into a government-recognized mechanism for ensuring educational quality and institutional accountability. This shift\u0026mdash;from the Accreditation Board for Medical Education in Korea (ABMEK) to the formal establishment of KIMEE (the Korean Institute of Medical Education and Evaluation)\u0026mdash;was largely driven by growing concerns within the medical community about the unchecked expansion of medical schools and declining educational standards [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith the introduction of the ASK 2019 standards (Accreditation Standards of KIMEE), which have been recognized by the World Federation for Medical Education (WFME), Korea\u0026rsquo;s accreditation framework has since moved toward greater alignment with global norms and expectations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. ASK 2019, the latest accreditation standard adopted in Korea, reflects a shift toward student-centered and performance-based medical education, emphasizing integrated curricula and aligning with both national needs and international trends [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the implementation of these standards has surfaced multiple tensions. While the educational field is shifting toward outcome-based and competency-oriented medical education, accreditation systems are expected to support and assess this transformation without uniformly adequate institutional capacity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As a result, institutions often experience strain in adapting to evolving expectations under resource and contextual constraints.\u003c/p\u003e \u003cp\u003eExisting literature on medical education accreditation has primarily focused on the policy evolution of the KIMEE framework and alignment with global standards [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Yet, there remains a lack of qualitative insight into how diverse stakeholders\u0026mdash;including faculty, administrators, evaluators, and students\u0026mdash;actually experience the accreditation process under ASK 2019. Research is needed to understand how stakeholders interpret the values embedded in accreditation, respond to its demands, and assess its contribution to educational quality and institutional development [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, while accreditation is conventionally characterized as a standardized and technically driven process, a growing body of academic literature has emphasized its inherently relational and interpretive nature. While conceptual papers have increasingly drawn attention to how factors such as the demeanor and professionalism of evaluators, the quality of communication between evaluators and institutions, institutional perceptions of fairness, and the degree of mutual trust may shape how accreditation procedures are implemented and experienced in practice [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], empirical research in this area remains limited\u0026mdash;particularly in the Korean context.\u003c/p\u003e \u003cp\u003eThis study seeks to address these gaps by exploring the perspectives and experiences of key stakeholders involved in medical school accreditation in Korea. Drawing on focus group discussions (FGDs) with self-evaluation committee members, visiting evaluators, KIMEE staff, and medical students, the study examines how accreditation is understood, negotiated, and enacted in practice. Based on these findings, it engages with the concept of an \"educational alliance\"\u0026mdash;a model that reconceptualizes accreditation not merely as a periodic assessment exercise, but as a relational, collaborative, and trust-based process oriented toward meaningful and sustainable educational improvement. While this concept has previously been introduced in global literature by Telio et al. (2015) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and more contextually in the Korean accreditation landscape by Jung et al. (2020) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], this study empirically extends and substantiates the educational alliance framework by grounding it in the lived experiences of stakeholders navigating the contemporary ASK 2019 cycle.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eStudy Design\u003c/p\u003e\n\u003cp\u003eThis qualitative study was designed to explore how key stakeholders involved in Korea’s medical education accreditation process interpret, engage with, and respond to the standards and procedures associated with ASK 2019. The study employed focus group discussions (FGDs) to capture a range of perspectives within and across stakeholder groups.\u003c/p\u003e\n\u003cp\u003eParticipants and Sampling\u003c/p\u003e\n\u003cp\u003eUsing purposeful sampling [10,11], we recruited 53 participants across four stakeholder groups: (1) self-evaluation committee members from 40 medical schools, (2) visiting evaluators with experience in accreditation site visits, (3) administrative staff affiliated with the medical education accreditation body, and (4) medical students who participated in accreditation-related activities. Selection criteria included direct experience with accreditation processes and willingness to participate in group dialogue. Participants were identified through institutional contacts, official invitations, and referrals from accreditation authorities and medical school administrators (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Insert Table 1 here]\u003c/p\u003e\n\u003cp\u003eData Collection\u003c/p\u003e\n\u003cp\u003eBetween December 2022 and January 2023, a total of 18 FGDs were conducted, ranging from 2 to 4 participants per group. Interviews were facilitated in either in-person or virtual formats depending on participant availability and geographic location. Discussions were guided by a semi-structured protocol organized around three domains: (1) perceptions and meanings of accreditation, (2) experiences with preparing for and participating in accreditation, and (3) suggestions for improvement. All sessions were audio-recorded with consent and transcribed verbatim.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of a university in South Korea (Approval No. HYUIRB-202307-011). All participants signed an informed consent form prior to participation. Participation was voluntary, and participants were informed of their right to withdraw from the study at any time without consequence. Confidentiality and anonymity of their responses were fully guaranteed.\u003c/p\u003e\n\u003cp\u003eData Analysis and Validity Evaluation\u003c/p\u003e\n\u003cp\u003eThis study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [12]. The collected data were analyzed using qualitative content analysis [13]. As a first step, the researcher listened to the audio recordings multiple times to become familiar with the participants and their narratives. The transcripts were then reviewed to extract relevant statements, which were grouped into initial units of meaning based on recurring ideas and implied meanings. The analysis then proceeded with categorizing these units into broader categories when thematic similarities were identified. Subsequently, overarching themes were derived that encompassed multiple categories and reflected shared patterns across stakeholder groups. To support this process, MAXQDA20 (VERBI GmbH, Berlin, Germany, 2019) was used to organize and code the data efficiently.\u003c/p\u003e\n\u003cp\u003eIn addition to peer debriefing and member checking, the researcher engaged in reflexive journaling throughout the data collection and analysis phases. This included documenting personal assumptions, expectations, and emotional responses to participant narratives, with the aim of increasing awareness of potential biases. Reflexivity was particularly critical given the researcher’s background in medical education and familiarity with the accreditation system. To mitigate interpretive bias, the researcher revisited the coding framework iteratively, sought alternative interpretations of ambiguous data, and critically examined how their positionality may have shaped the thematic structure. Through these reflexive practices, the researcher aimed to enhance the confirmability and credibility of the findings.\u003c/p\u003e\n\u003cp\u003eAs a common qualitative research technique, direct quotations from participants were included to illustrate key findings and preserve the richness of stakeholder perspectives. Quotations were selected based on their representativeness and clarity in conveying the theme. However, due to methodological constraints, not all participant narratives could be included. To further ensure trustworthiness, the researcher regularly engaged in peer debriefing with colleagues familiar with the research context and shared preliminary findings with selected participants to verify the accuracy and authenticity of interpretations\u0026nbsp;[14].\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThematic analysis of the focus group discussions yielded five major themes that captured the complex and multifaceted nature of accreditation experiences among Korean medical education stakeholders. These themes reflect both systemic challenges and relational tensions embedded within the accreditation process. Table 2 presents the main theme and representative subthemes.\u003c/p\u003e\n\u003cp\u003e[Insert Table 2 here]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrategic Compliance vs. Authentic Quality Improvement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStakeholders broadly acknowledged that medical education accreditation played a pivotal role in prompting institutional change and elevating educational standards. Many emphasized that accreditation was instrumental in ensuring the basic qualifications and infrastructure of medical education, and even served as a catalyst for institutional investment and recognition:\u003c/p\u003e\n\u003cp\u003e“Accreditation has led to significant budget investments, which in turn has contributed to the university’s substantial development. Especially, the increased interest from foundations and stakeholders toward the university due to accreditation cannot be ignored.” (Self-Evaluation Committee 10, FGI 4)\u003c/p\u003e\n\u003cp\u003eMoreover, the process encouraged internal discussions around quality assurance and fostered a culture that increasingly values continuous improvement:\u003c/p\u003e\n\u003cp\u003e“Without accreditation, we would have been like ‘a big fish in a small pond,’ unaware of the situations in other medical schools. It has provided us with insights into areas that need continuous quality improvement and has fostered a culture emphasizing the importance of ongoing enhancement.” (Self-Evaluation Committee 11, FGI 4)\u003c/p\u003e\n\u003cp\u003eNevertheless, participants also expressed concern that the process sometimes led to performative compliance rather than genuine transformation. Several described a sense of \"checklist fatigue\" where the emphasis shifted from educational reflection to fulfilling formal requirements:\u003c/p\u003e\n\u003cp\u003e“We know what to write and what they want to hear. It’s less about our identity as a school and more about aligning with templates.” (Self-Evaluation Committee, FGD 10)\u003c/p\u003e\n\u003cp\u003eDespite these limitations, many still regarded accreditation as a useful tool to initiate otherwise difficult conversations within institutions and align stakeholders around shared goals:\u003c/p\u003e\n\u003cp\u003e“I firmly believe that accreditation has indeed contributed to the improvement of the medical school’s quality. Especially when trying to reach a consensus among school members… when I mention that ‘it is part of the medical education accreditation standards,’ they become quiet.” (Self-Evaluation Committee 9, FGI 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInstitutional Disparities and Resource Dependency\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFocus group discussions highlighted considerable disparities in accreditation readiness among institutions. Resource constraints—whether in faculty numbers, funding, or administrative support—impacted schools’ ability to prepare effectively. Several smaller schools shared that preparing for accreditation often competed with core teaching and clinical responsibilities:\u003c/p\u003e\n\u003cp\u003e“We don’t have the luxury to talk about innovation—we’re just trying to survive the paperwork.” (Self-Evaluation Committee 21, FGD 7)\u003c/p\u003e\n\u003cp\u003e“Unlike large universities with dedicated educational staff, our team is all clinical faculty with heavy schedules. It’s almost impossible to manage both.” (Self-Evaluation Committee 23, FGD 8)\u003c/p\u003e\n\u003cp\u003eThe presence—or absence—of medical education experts significantly shaped how schools approached accreditation. Institutions with internal expertise were able to conduct faculty development sessions and interpret ASK 2019 standards with more confidence:\u003c/p\u003e\n\u003cp\u003e“Our university has the capacity to conduct internal workshops because we have KIMEE representatives who have experience as visiting evaluators.” (Self-Evaluation Committee 7, FGI 3)\u003c/p\u003e\n\u003cp\u003eOthers, however, relied heavily on KIMEE-led external workshops and faced challenges in localizing the standards to their own contexts:\u003c/p\u003e\n\u003cp\u003e“We tend to rely solely on external workshops organized by KIMEE as we lack human resources to conduct our own training.” (Self-Evaluation Committee 9, FGI 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEvaluator Conduct and the Credibility of Outcomes\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants widely recognized the importance of evaluator professionalism in shaping the legitimacy and emotional tone of the accreditation process. While several participants noted positive experiences:\u003c/p\u003e\n\u003cp\u003e“One evaluator told us our efforts were visible and appreciated. That changed the entire team’s morale.” (Self-Evaluation Committee 13, FGD 5)\u003c/p\u003e\n\u003cp\u003eOthers recalled less constructive interactions:\u003c/p\u003e\n\u003cp\u003e“In one case, an evaluator corrected a faculty member mid-sentence in a demeaning tone. That kind of interaction shuts down honest communication.” (Self-Evaluation Committee 16, FGD 6)\u003c/p\u003e\n\u003cp\u003eEvaluator expertise was also seen as crucial. Participants expected evaluators not only to apply standards consistently, but also to contextualize them based on a school’s mission and resources:\u003c/p\u003e\n\u003cp\u003e“At times, it felt as though our school’s smaller size led to assumptions about our performance, with limited recognition of our unique mission and context.”\u003c/p\u003e\n\u003cp\u003e(Self-Evaluation Committee 1, FGD 1)\u003c/p\u003e\n\u003cp\u003eDespite concerns raised by self-evaluation committee members regarding evaluator conduct and perceived inconsistencies, visiting evaluators offered a contrasting perspective. Many of them acknowledged KIMEE’s sustained efforts to improve evaluator professionalism and consistency through structured development programs. These included inter-rater reliability workshops, team leader training, and frequent deliberative meetings during the evaluation process itself. Such efforts were seen as valuable for calibrating standards and fostering shared understanding among evaluators.\u003c/p\u003e\n\u003cp\u003e“It was quite satisfactory to have all area-specific committee meetings gather together. These meetings help. I believe that enhancing the understanding of accreditation standards and improving evaluation expertise can be achieved prior to the visiting evaluation.”\u003c/p\u003e\n\u003cp\u003e(Visiting Evaluator 2, FGI 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAsymmetries in Trust and Communication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral participants described interactions with evaluators and KIMEE as overly formal, hierarchical, and time-constrained. This hindered opportunities for mutual understanding and knowledge exchange:\u003c/p\u003e\n\u003cp\u003e“We want feedback that feels like dialogue, not judgment. Right now, it’s more of a one-way street.” (KIMEE Staff 3, FGD 1)\u003c/p\u003e\n\u003cp\u003e“There was no chance to ask questions back or explain why certain decisions were made. It felt like we were being talked at, not with.” (Self-Evaluation Committee 14, FGD 5)\u003c/p\u003e\n\u003cp\u003eTime pressure was especially felt during site visits, which often lacked space for schools to introduce themselves and build rapport. Participants recommended longer visits or structured pre-visit engagements to foster relational trust.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCyclical Reform Fatigue and Accountability Dilution\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough stakeholders recognized that accreditation can drive continuous improvement, they also voiced concerns about reform fatigue. The repetitive nature of documentation, leadership turnover, and short institutional memory diminished the impact of post-accreditation improvement plans:\u003c/p\u003e\n\u003cp\u003e“Improvement reports are just words on paper. By the time the next cycle comes, no one remembers what was promised.” (Self-Evaluation Committee 35, FGD 12)\u003c/p\u003e\n\u003cp\u003e“Those who write the reports and those who implement them are rarely the same people. It’s like sending a message into the void.” (Self-Evaluation Committee 31, FGD 11)\u003c/p\u003e\n\u003cp\u003eNevertheless, for some research participants—particularly visiting evaluators—accreditation work was viewed as a valuable learning experience and a chance to grow professionally in the field of medical education:\u003c/p\u003e\n\u003cp\u003e“I could learn about a new field and felt really satisfied with the process… undergoing reviewer committee’s scrutiny allowed us to improve our report writing skills.” (Visiting Evaluator 2, FGI 1)\u003c/p\u003e\n\u003cp\u003ePerceptions of accreditation varied significantly between stakeholder groups. While many self-evaluation committee members described the process as burdensome and repetitive, some visiting evaluators reflected on it as an opportunity for professional growth and deeper insight into educational practices. These contrasting experiences illustrate how accreditation can be interpreted differently depending on one's role and proximity to institutional constraints.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study illuminates the nuanced and multi-dimensional experiences of stakeholders engaged in the Korean medical education accreditation process. While accreditation has long served as a mechanism for quality assurance and institutional accountability, our findings highlight that its implementation is shaped not only by formal standards but also by relational dynamics, institutional capacity, and the interpretive practices of those involved. These insights challenge the assumption that accreditation is merely a technical or standardized procedure, suggesting instead that it is negotiated at the intersection of shared ideals and practical constraints.\u003c/p\u003e\n\u003cp\u003eFirst, while accreditation was broadly recognized as a catalyst for institutional development, many participants described a tension between strategic compliance and authentic quality improvement. While the process prompted significant investments and encouraged internal dialogue around educational standards, it also generated fatigue due to repetitive documentation and a checklist-oriented culture. Nonetheless, some participants viewed accreditation as an opportunity to legitimize educational conversations and foster a culture of continuous improvement. Accreditation, in this view, functioned not only as an external requirement but also as a vehicle for internal mobilization and collective responsibility.\u003c/p\u003e\n\u003cp\u003eSecond, participants emphasized persistent disparities in institutional resources, which posed challenges to equitable engagement with the accreditation process. Schools with limited human or financial capacity, or without in-house medical education expertise, often found it difficult to meet expectations and relied heavily on external workshops. In contrast, institutions with internal accreditation experts were able to conduct faculty training and align standards with local development efforts. These differences highlight the need for accreditation policies that accommodate institutional diversity and provide differentiated support mechanisms.\u003c/p\u003e\n\u003cp\u003eFor example, while some schools have faculty members with extensive accreditation experience or dedicated educational staff capable of conducting internal training and interpreting standards independently, others lack such personnel and face considerable limitations in administrative or financial capacity. These disparities suggest that the uniform application of standards may inadvertently reproduce structural inequities and undermine the credibility and fairness of the accreditation process. Therefore, accrediting bodies should consider context-sensitive policy adaptations—such as extending pre-visit consultation opportunities for resource-limited schools, offering flexible timelines for site visits, providing annotated guides with case-based interpretations of standards, and supporting post-visit improvement planning through institutional coaching or mentoring. Such differentiated approaches can enhance not only procedural fairness but also the substantive legitimacy and sustainability of the accreditation system.\u003c/p\u003e\n\u003cp\u003eThird, the demeanor, expertise, and communicative conduct of evaluators emerged as crucial to the perceived fairness and impact of accreditation. Participants valued evaluators who not only understood the standards but were also able to contextualize them based on the unique missions, histories, and constraints of individual schools. Mutual respect, empathy, and clarity of communication were repeatedly cited as key to creating a positive and productive evaluation experience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings reinforce the idea that the perceived legitimacy and trustworthiness of accreditation depend not only on the consistent application of standards, but also on the quality of interpersonal interactions between evaluators and institutions. Specifically, how evaluation is communicated—whether evaluators demonstrate respect, contextual awareness, and empathetic dialogue—plays a central role in how accreditation is received and interpreted by stakeholders. This resonates strongly with the concept of relational accountability, which emphasizes that evaluative legitimacy is shaped as much by human relationships as by procedural rigor.\u003c/p\u003e\n\u003cp\u003eIn this study, institutions reported higher levels of trust and acceptance of accreditation outcomes when evaluators listened attentively, acknowledged institutional missions, and provided respectful, constructive feedback. These encounters often led to greater internal engagement with quality improvement. In contrast, when feedback was delivered in a rigid, dismissive, or context-blind manner, participants described experiencing distrust, defensiveness, and skepticism about the fairness of the entire process. These examples illustrate that for accreditation to be perceived as credible, it must be not only technically sound but also relationally sensitive in its delivery and interpretation.\u003c/p\u003e\n\u003cp\u003eFourth, asymmetries in communication and limited opportunities for mutual exchange were identified as ongoing challenges. While participants appreciated the role of accreditation in prompting conversations about quality, they also expressed frustration with the lack of dialogic engagement during and after site visits. Many suggested establishing more iterative and interactive communication mechanisms—before, during, and after evaluations—to ensure shared understanding and reduce misinterpretation. Such changes could help shift the process from a one-directional assessment model to a more collaborative and relational form of engagement.\u003c/p\u003e\n\u003cp\u003eFinally, the study sheds light on reform fatigue. Although accreditation cycles were designed to promote continuous quality improvement, stakeholders reported that improvement plans were often symbolic and inconsistently implemented. Leadership turnover, the erosion of institutional memory, and a structural disconnect between planning and implementation contributed to this fatigue. This dual burden of quality enhancement and administrative overload reflects the findings of Blouin et al. (2018), who observed that while accreditation fosters quality-oriented processes, it also generates negative consequences for faculty morale, innovation, and institutional efficiency [2].\u003c/p\u003e\n\u003cp\u003eThese concerns are consistent with previous findings suggesting that cyclical accreditation processes can lead to fatigue and diminish intrinsic motivation for sustained reform, while also fostering a “checklist mentality” that favors formal compliance over genuine innovation [3]. As highlighted in broader literature on educational reform, maintaining institutional memory through leadership continuity and internal capacity-building remains essential for long-term improvement [15].\u003c/p\u003e\n\u003cp\u003eAt the same time, some participants found the process personally meaningful, citing opportunities for professional development and greater insight into educational practice. This duality—between fatigue and formative value—highlights the need for accreditation systems that not only enforce standards but also support growth and learning. Stakeholders simultaneously experienced accreditation as a repetitive and burdensome obligation—marked by administrative overload and uncertainty—yet also as a meaningful opportunity for institutional reflection, collaborative dialogue, and educational development. This tension suggests that how accreditation is designed and delivered can significantly shape whether it is perceived as punitive or developmental.\u003c/p\u003e\n\u003cp\u003eTaken together, these findings support a reconceptualization of accreditation not merely as a compliance mechanism but as a form of educational alliance—a trust-based partnership between institutions and evaluators [7,9]. This framework emphasizes mutual understanding, co-construction of meaning, and sustainable quality improvement through ongoing dialogue [9]. From this perspective, accreditation is not simply a standardized or technical process; rather, it is a negotiated practice situated at the intersection of shared educational ideals and institutional constraints. By moving beyond procedural adherence and incorporating relational and contextual dimensions into evaluation systems, accreditation can evolve into a more credible, equitable, and meaningful driver of educational quality.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study has explored the perspectives and experiences of key stakeholders involved in medical education accreditation in South Korea. Drawing on insights from a broad range of institutional voices, we find that accreditation is experienced not merely as a procedural or evaluative mechanism, but as a complex and relational process situated within the realities of institutional capacity, resource disparities, and evolving cultural expectations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne of the most salient findings is that the perceived effectiveness and legitimacy of accreditation depend not only on \u0026apos;what is evaluated\u0026apos;, but on \u0026apos;how evaluation is conducted\u0026apos;. Evaluators, positioned as both assessors and communicators, play a pivotal role in shaping trust, morale, and institutional engagement. At the same time, structural challenges\u0026mdash;including limited time for interaction, asymmetrical communication, and inconsistent follow-through\u0026mdash;undermine the sustainability and credibility of the process.\u003c/p\u003e\n\u003cp\u003eIn response to these dynamics, we propose the framework of an educational alliance as both a conceptual and practical alternative to traditional accreditation paradigms. This alliance is grounded in mutual trust, reciprocal dialogue, shared purpose, and contextual responsiveness. It reframes accreditation from a one-way evaluative act into a collaborative and evolving partnership that supports institutional growth, reflection, and long-term improvement. Our findings suggest that stakeholders are not only open to such a shift\u0026mdash;they are actively seeking it. They call for evaluation systems that are more dialogic than directive, more adaptive than rigid, and more supportive than punitive.\u003c/p\u003e\n\u003cp\u003eBy situating accreditation within the framework of an educational alliance, we invite a rethinking of the purpose and practice of accreditation. This reconfiguration offers a pathway toward more transparent, inclusive, and sustainable evaluation systems\u0026mdash;ones that bridge the gap between policy and practice, accountability and capacity, evaluation and education. While grounded in the Korean context, this framework may also offer valuable insights for global efforts to redesign accreditation in ways that prioritize relational trust, institutional learning, and meaningful quality enhancement.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASK 2019\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAccreditation Standards of the Korean Institute of Medical Education and Evaluation (2019)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKIMEE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKorean Institute of Medical Education and Evaluation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWFME\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Federation for Medical Education\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author sincerely thanks all participants in the focus group discussions—including self-evaluation committee members, accreditation site visit evaluators, KIMEE staff, and medical students—for their invaluable insights and contributions to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYJK conceptualized the study, conducted data curation and formal analysis, developed the methodology, and performed validation. YJK also wrote the original draft and reviewed and edited the final manuscript. The author read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets for this article are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by INHA UNIVERSITY Research Grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eORCID iDs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYe Ji Kang https://orcid.org/0000-0003-1711-2394\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMeng KH. History of the medical education accreditation system in Korea: Implementation and activities in the early stages. \u003cem\u003eJ Educ Eval Health Prof.\u003c/em\u003e 2020;17:29. https://doi.org/10.3352/jeehp.2020.17.29\u003c/li\u003e\n\u003cli\u003eBlouin D, Tekian A, Kamin C, Harris IB. The impact of accreditation on medical schools\u0026rsquo; processes. \u003cem\u003eMed Educ\u003c/em\u003e. 2018;52(2):182\u0026ndash;91. https://doi.org/10.1111/medu.13471\u003c/li\u003e\n\u003cli\u003eTaber S, Leithead C, Naidoo K, Pilapil M, Battista R. A \u0026ldquo;fit for purpose\u0026rdquo; framework for medical education accreditation system design. \u003cem\u003eBMC Med Educ\u003c/em\u003e. 2020;20:8. https://doi.org/10.1186/s12909-019-1912-z\u003c/li\u003e\n\u003cli\u003eYoo HH, Kim MK, Yoon YS, Lee KM, Lee JH, Hong SJ, et al. Changes in the accreditation standards of medical schools by the Korean Institute of Medical Education and Evaluation from 2000 to 2019. \u003cem\u003eJ Educ Eval Health Prof\u003c/em\u003e. 2020;17:2. https://doi.org/10.3352/jeehp.2020.17.2\u003c/li\u003e\n\u003cli\u003eLim KY. A proposal for the future of medical education accreditation in Korea. \u003cem\u003eJ Educ Eval Health Prof.\u003c/em\u003e 2020;17:32. https://doi.org/10.3352/jeehp.2020.17.32\u003c/li\u003e\n\u003cli\u003eKorean Institute of Medical Education and Evaluation (KIMEE), Korean Institute of Medical Education and Evaluation. 20 years of footsteps of KIMEE. In: Proceedings of the symposium on the 20th anniversary of medical education accreditation: Past, present, and future of KIMEE (Brochure) (Nov 8). Seoul, Korea; 2019.\u003c/li\u003e\n\u003cli\u003eJung H, Jeon WT, An S. Is the accreditation in medical education an opportunity or a burden? \u003cem\u003eKorean Med Educ Rev\u003c/em\u003e. 2020;22(1):16\u0026ndash;27. https://doi.org/10.17496/kmer.2020.22.1.16\u003c/li\u003e\n\u003cli\u003eChae SJ. Exploration of Development Tasks of Medical Education Accrediation Trhough In-dept Interviews. J of Humanities and Social Sciences 21 2021; 12(5):1605-1616.\u003c/li\u003e\n\u003cli\u003eTelio S, Ajjawi R, Regehr G. The \u0026ldquo;educational alliance\u0026rdquo; as a framework for reconceptualizing feedback in medical education. \u003cem\u003eAcad Med\u003c/em\u003e. 2015;90(5):609\u0026ndash;14. https://doi.org/10.1097/ACM.0000000000000585\u003c/li\u003e\n\u003cli\u003eMerriam SB, Tisdell EJ. Qualitative research: A guide to design and implementation. Hoboken, NJ: John Wiley \u0026amp; Sons; 2015.\u003c/li\u003e\n\u003cli\u003ePowell RA, Single HM. Focus groups. \u003cem\u003eInt J Qual Health Care\u003c/em\u003e. 1996;8(5):499\u0026ndash;504. https://doi.org/10.1093/intqhc/8.5.499\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. \u003cem\u003eAcad Med\u003c/em\u003e. 2014;89(9):1245\u0026ndash;51. https://doi.org/10.1097/ACM.0000000000000388\u003c/li\u003e\n\u003cli\u003eKrippendorff K. Content analysis: An introduction to its methodology. Thousand Oaks, CA: Sage Publications; 2018.\u003c/li\u003e\n\u003cli\u003eLincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks, CA: Sage Publications; 1985.\u003c/li\u003e\n\u003cli\u003eFrank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. \u003cem\u003eMed Teach\u003c/em\u003e. 2010;32(8):638\u0026ndash;45. https://doi.org/10.3109/0142159X.2010.501190\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Details of stakeholder recruitment\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eNumber of Participants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eNumber of FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003eRecruitment details\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSelf-evaluation committee members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e● One representative professor from each of the 40 medical schools in Korea.\u003c/p\u003e\n \u003cp\u003e● All have participated in at least two medical school accreditation cycles and possess expertise in medical education and evaluation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eVisiting evaluators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e● Are seven members of the medical school accreditation site visit team (one representative from each committee at the Korean Institute of Medical Education and Evaluation).\u003c/p\u003e\n \u003cp\u003e● Have expertise in ASK 2019 accreditation standards and have participated in at least one site visit. They are familiar with the evaluation process and criteria.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eStaff members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e● Are current employees of KIMEE\u003c/p\u003e\n \u003cp\u003e● Have a high level of understanding in all aspects of the medical education accreditation process, serving as practical support for the accreditation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eMedical school students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 299px;\"\u003e\n \u003cp\u003e● Have participated in accreditation activities, such as writing student reports or taking part in student interviews.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Theme and Representative Subthemes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eRepresentative Subthemes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e1. Strategic Compliance vs. Authentic Quality Improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eChecklist mentality, short-term focus, leadership discontinuity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e2. Institutional Disparities and Resource Dependency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eHuman/material constraints, external reliance, inequity in readiness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e3. Evaluator Conduct and the Credibility of Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eRelational tone, evaluator attitude, contextual insensitivity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e4. Asymmetries in Trust and Communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eOne-way feedback, time-limited interaction, miscommunication risk\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e5. Reform Fatigue and Accountability Dilution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 364px;\"\u003e\n \u003cp\u003eSymbolic improvement reports, low follow-through, organizational memory loss due to leadership rotation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical School Accreditation, Qualitative Research, Educational Alliance, Stakeholder Perspectives","lastPublishedDoi":"10.21203/rs.3.rs-6575482/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6575482/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Accreditation plays a critical role in ensuring educational quality and institutional accountability. In South Korea, a centralized accreditation system for medical schools has been in place for over two decades. While the adoption of updated national standards in 2019 aligned the system with international accreditation frameworks, little is known about how diverse stakeholders perceive and engage with these evolving standards in practice. This study aims to explore how stakeholders involved in Korean medical education interpret, navigate, and respond to the accreditation process, with a particular focus on relational dynamics and institutional trust.\u003c/p\u003e\n\u003cp\u003eMethods: A qualitative design was employed using 18 focus group discussions (FGDs) with 53 participants, including self-evaluation committee members, site visit evaluators, staff from the national medical education accreditation body, and medical students. Data were analyzed inductively through content analysis using MAXQDA, following the COREQ guidelines.\u003c/p\u003e\n\u003cp\u003eResults: Five major themes were identified: (1) strategic compliance versus authentic quality improvement, (2) institutional disparities and resource dependency, (3) evaluator conduct and the credibility of outcomes, (4) asymmetries in trust and communication, and (5) cyclical reform fatigue. Notably, participants emphasized the demeanor and interpersonal conduct of evaluators as critical to the perceived fairness and impact of the accreditation process—highlighting the importance of relational factors in an often standardized system.\u003c/p\u003e\n\u003cp\u003eConclusions: This study empirically extends the concept of an \"educational alliance\"—a model previously introduced in the literature that reconceptualizes accreditation not merely as periodic assessment, but as a relational, collaborative, and trust-based process aimed at meaningful educational improvement. By foregrounding mutual understanding, contextual responsiveness, and relational accountability, the educational alliance model offers a more sustainable and meaningful approach to quality improvement in medical education. These findings offer timely insights for accreditation reform in Korea and other health professions education systems navigating similar tensions.\u003c/p\u003e","manuscriptTitle":"From Technical Evaluation to Educational Alliance: Stakeholder Perspectives on Medical School Accreditation in Korea","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 10:32:50","doi":"10.21203/rs.3.rs-6575482/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-15T07:01:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-14T08:48:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-14T08:46:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-05-02T05:01:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5f1a63d-77ea-45e5-85ba-1892609231f1","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-13T10:23:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-05 10:32:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6575482","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6575482","identity":"rs-6575482","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}