Supplementary Review Results

Kitasato University

Basic Information of the Institution
Ownership: PrivateLocation: Tokyo, Japan

Accreditation Status
Year of the Review: 2020
Accreditation Status: accredited （Accreditation Period: April.1.2021 – March.31.2024）

Kitasato University

Supplementary Reviewfor Kitasato University
Overview
Regarding Kitasato University, as the “Summary of the Emergency Review to Ensure
Fairness in Admissions to Medical Programs” published by MEXT on December 14,
2018 uncovered issues in student selection for medical programs, we established aninvestigative subcommittee inside the University Accreditation Committee in 2019 andexamined the validity of results from the 2016 University Accreditation (certifiedevaluation and accreditation). That examination verified major issues in “enrollment”,“governance”, and “internal quality assurance” and as a result, the determination of the2016 University Accreditation Results stating that the University conformed to University
Standards was overturned and the University was deemed noncompliant. Also,
assessment for accreditation in this Supplementary Review based on the state ofimprovement for the three standards of “Student Enrollment”, “Management”, and“Internal Quality Assurance” that were the cause of the denial of accreditation was carriedout alongside a review on the state of improvement for the five suggestions from theprevious University Accreditation Results, including “Iinternal Qquality Aassurance”.
To address these issues in student selection, Kitasato University, under theleadership of the President, established an Admissions Review Committee omprised ofmembers from the University Admissions Committee with the Vice President ofAdmissions as Chair and a Third-Party Committee comprised of outside experts, both
based around the Deans’ Committee that discusses and decides key items involving
educational and research activity throughout the University. Interdivisional Committees
such as the Kitasato University Self-Study Committee (hereafter referred to as“University Committee”) and Faculty Councils, Related Committees, Deans within eachschool and all entities related to donations (including auditors) are all working together
toward improvements. As a result, broad improvements were made to major issues andthe University was determined to satisfy University Standards.
First, for“Student Enrollment”, determinations for successful applicants andwaitlisted applicants to the School of Medicine were conducted fairly, but the Dean andthe Admissions Committee Chair decided which applicants were accepted from thewaitlist even though acceptance criteria were not clearly established. Grades were notalways the primary determinant for acceptance and priority was given to some applicants
who could be viewed as more suitable to becoming physicians and those who had strong
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reasons to apply based on school records and applicant interview forms. This was foundto be inappropriate because it left room for arbitrary decisions to intervene in student
selection. As a result, the University created a Third-Party Committee to explore how toprevent this situation from recurring and investigate its cause, formulated the “MedicalAdmissions Committee Regulations” and the “Medical Admissions Administration
Committee Regulations,” reviewed the organization and roles of committee members
involved in admissions, and clarified the management and operation of admissions. It also
enacted improvements to ensure fairness and transparency in the admissions system byinstituting the “Internal Regulations on the Determination and Advancement for
Waitlisted Candidates” regarding how to implement advancement procedures and theprocesses for determining rules and ranking waitlisted applicants as well as establishedmechanisms for the President to scrutinize acceptance decisions based on these internal
regulations.
The above improvements were enacted and the Third-Party Committee
determined that 2019 admissions were conducted fairly. The University also establishedan Admissions Review Committee based primarily on the Kitasato University
Admissions Examination Committee, examined the development status of the admissions
administration system and regulations, and conducted investigations and inspections ofacceptance decisions across all schools. A review of the Admissions Review Committee
was conducted for 2020 admissions. In order to steadily improve fairness and impartiality
in enrollment, the Kitasato University Admissions Examination Committee will examine
the structure of the review system - including graduate school admissions - moving
forward and the University is expected to faithfully implement initiatives forimprovement.
The University is working to reform awareness by demanding appropriate
student selection and having the President and the Vice President of Admissions explain
to University faculty and staff the circumstances behind admissions of waitlisted
applicants in 2018 School of Medicine admissions in the Dean’s Committee and theFaculty Council. It is also considering engaging in Faculty Development (FD) and Staff
Development (SD) throughout the University in the future to ensure fair admissions.
While the University is enacting the above initiatives to prevent recurrence throughout
the University, they are still in their initial stages and the University should persist withreviews and improvements, including reviews of graduate school admissions andUniversity-wide FD and SD involving student selection.
Regarding “Management” even though the authority, etc. of the President, Vice
President and Faculty Council was clearly defined in regulations, the Medical Admissions
2Kitasato UniversityCommittee and the Medical Faculty Council that were supposed to determine thewaitlisted applicants to admit into the School of Medicine left the decision to the Dean
and the Admissions Committee Chair, resulting in a system that did not function withadequate governance. Internal audits also indicated that student selection did notguarantee fairness. In response, the University asked the President to explain theconditions for admitting applicants in 2018 School of Medicine admissions to the Deanof each school in the Dean’s Committee, demanded that appropriate student selection beconducted, established the Admissions Review Committee mentioned above, investigatedand inspected admissions in each school, and examined how well the administration
system, related regulations, etc. for admissions were being maintained. University auditsthat include student selection have been conducted since 2020 with the Audit Officeplaying a central role. Audits are conducted based on a University audit plan comprisedof three auditors, including one newly appointed auditor with experience in University
Management in order to strengthen University audits. A system has been establishedunder this plan where auditors work in connection with the Audit Office, both parties
attend important meetings like the University Committee, etc., and auditors scrutinize
documents while holding hearings with the President, etc. to verify whether academic
duties are being carried out properly and effectively. Through these initiatives, thePresident, Deans, each school, etc. carry out their duties based on the responsibilities laidout for them in regulations. Administrative issues involving admissions are mostly being
improved because additional checks and reviews are carried out by specializedorganizations. Moving forward, the University should make sure to conduct audits basedon the “2020 Audit Plan”.
For “Internal Quality Assurance” because the previous University Accreditationsuggested revising the University’s review systems, regulations, etc., in 2017 theUniversity Committee and the Self-Study Committee from the undergraduate andgraduate schools began cooperating with each other and the three regulations “InternalQuality Assurance Check and Review Regulations” (formerly “Check and ReviewRegulations”), “Kitasato Self-Study Committee Regulations,” and “Regulations on theEstablishment of the Check and Review Office” were revised and maintained in order toimprove and reform the results of checks and reviews. However, since inappropriate
actions were taken in School of Medicine admissions, the University should take nomeasures that would make checks and reviews simple bureaucratic acts and must examine
the efficacy of the internal quality assurance system. Kitasato University checked andreviewed the cause of these issues and found that: 1) checks, reviews, and their reforms
were left to each undergraduate and graduate school, 2) the University Committee only
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met a handful of times each year, so the committee was unable to lead improvements andreforms on campus, 3) there were few opportunities to regularly share accreditation
results between schools, so the Self-Study Committee from each school and theUniversity Committee could not cooperate effectively. In order to resolve these issues,
the “Kitasato Self-Study Committee Regulations” were revised again, Deans were mademembers of the University Committee as selected via each school’s “CommitteeRegulations,” committee meetings were held monthly and included full-time auditors andthe Audit Office. From these reforms, the Vice Presidents and Deans were added to theUniversity Committee with the President as the Chair, activities towards improvement
and reform were strengthened, and plans put in place to share information throughout theUniversity. Also, results from the Admissions Review Committee’s investigations are
now confirmed by Deans and the University Committee. While still in the beginningphases, these initiatives have already shown improvements towards the suggestions forimprovement in the 2016 University Accreditation and the issues indicated in the 2019
examination results. Additionally, in order to increase the objectivity and suitability ofchecks and reviews, ensure quality in University activities, and promote initiatives that
contribute to further improvements and advancements, in the future, the University is
expected to examine the effectiveness of functions in the internal quality assurance
system and add additional improvements based on advancements to establish the Kitasato
External Review Committee in 2020.
In addition, four of the suggestions for improvement included with the 2016
University Accreditation are already seeing improvement, with the exception of internal
quality assurance. However, the School of Medicine’s 1.04 ratio of student enrollment tothe student enrollment cap is high. The University has employed a special informal
consultation system for students with poor grades in addition to establishing aconsultation system based on head teacher and class representative and though it has
worked to foster academic motivation by providing individual guidance and lifelong
academic encouragement, the ratio was still relatively high as of May 1, 2020 and requires
continued improvement.
The University has conducted swift and appropriate investigations since thedenial of accreditation by this Association and MEXT’s findings, with improvements
already being made for the issues in question from results that promoted specificimprovements, etc. On the other hand, some initiatives are still being carried out andimprovements to the system have only recently been made, so we hope that the University
will continue to implement improvements for additional development.

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Suggestions for Improvement
Student Enrollment
The ratio of student enrollment to the student enrollment cap in the School ofMedicine in 2020 is high at 1.04. Therefore, the University should continue toimprove undergraduate and graduate quota management.

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