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International Society for Prosthetic and Orthotics (ISPO) Cambodian School of Prosthetics and Orthotics (CSPO)

Category II Inspection & Final Examinations 20-23 September 2005

Participants CSPO: Mary Scott, Cambodia Trust Acting Country Director

Sisary Kheng, CSPO Manager Lisa Hjelmstrom, CSPO Advisor Faculty

Students ISPO: Dan Blocka, Education Chair Dr. Bakht Sarwar, Education Committee Member Introduction The Cambodian School of Prosthetics and Orthotics commenced its operation in 1993. The first intake of six students commenced studies in January 1994. There have been 14 intakes overall with an average intake of 12 students per year (rangin from 10 to 14 students). The School has been recognized as an ISPO Category II school for training and education in Prosthetics and Orthotics for two subsequent periods from 1999 to the present. Since the previous ISPO recognition was granted for a 3-year period, the school officially requested an ISPO inspection and participation in the final examinations. For this purpose ISPO selected Dan Blocka and Dr. Bakht Sarwar to lead the inspection process. The inspection and examinations occurred between the period of September 20 to 23, 2005. The following report will give a summary of the observations and findings of the ISPO team and also give concluding remarks and recommendations as it pertains to continued recognition. The current ISPO Category II Information Package will be used as the framework to ensure the competencies required to reach a Category II level of practitioner are met. The description of the Professional Profile and the Learning Objectives/Competencies for a Category II professional that are sections 2 and 4 respectively in the ISPO Category II Information Package will also be used in the inspection process. They will be used as a template to ensure the primary academic and practical elements are encompassed in the program. This inspection will also include a final examination process that will be outlined in more detail in the report.

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Methodology of Procedures The assessors interviewed the academic management team, staff and students involved in the CSPO and discussed all aspects of the course with them. They also examined the school facilities in all areas. The document outlining the method and schedule for the inspection is included in Appendix I. Please refer to this document for more details of how this process was carried out. The ISPO report from the previous inspection will be used as a source to track how school acted upon the previous recommendations/changes. The report is attached at Appendix II. The Assessors were also members of the Examination Board for the Final Examination process of the graduating class 2005. The examination process took place on Wednesday September 21 and Thursday September 22. RESULTS School Inspection/Accreditation The ISPO assessment team followed the protocol below over the time period which involved direct interviews, discussions, and visible inspection. For the most part this task was made very easy due to the very thorough documentation the school provided to the inspection team (This documentation will be made available to those at the Education Committee Meeting) The documentation followed along with the protocol outlined in Appendix I as per the following:

i) Entry level to course. ii) Content of course with regards theoretical subjects, workshop practice, and

clinical practice. iii) Duration of course with regard overall time and hours available for instruction. iv) Recognition of course by the Education and Health authorities.

- National Diploma of Prosthetics & Orthotics is shown in Appendix VI v) Level of training compared with other paramedical professionals. vi) Teaching staff available for theoretical subjects. vii) Staff available for prosthetic and orthotic teaching. viii) Proper examination of all subjects. ix) High standard of practical and clinical work. x) Failure rates. xi) Access to patients. xii) Access to medical and other paramedical personnel. xiii) Teaching materials. xiv) Facilities such as classrooms, workshops, equipment, clinic areas. xv) Employment prospects of graduates. xvi) Internship arrangements. xvii) Certification of course.

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xviii) Permanency of course. Since the documentation is so organized and thorough, there is little or no reason to comment on areas where the ISPO standards are met or exceeded and also where the situation is satisfactory. This is especially so with a school that has a record of being officially recognised by ISPO over the past 6 years. Due to this fact, the report will only indicate and comment on items where there have been changes or where it is felt warranted due to related recommendations that will be made. Comments on the elements above: ii) Content of course with regards theoretical subjects, workshop practice, and clinical practice. iii) Duration of course with regard overall time and hours available for instruction The CSPO program overall has not changed to any great degree but there is a shift occurring in the structure of the modules as shown in Appendix III. This has occurred overall to streamline some of the content in areas because of the fact that incoming students have a more competent baseline of knowledge and skills. It has also occurred to concentrate more of the content into the Clinical Placement to deepen the experiences at this level. The method of Cased Based Learning has now been implemented into the curriculum to enhance the clinical approach taken by the students and to improve their clinical problem solving skills. The one area that has been reduced and consolidated more is the area of upper limb orthotics and prosthetics and also spinal orthotics. This may be an area to monitor to ensure that the essential elements of these areas are still covered appropriately. vi) Teaching staff available for theoretical subjects. vii) Staff available for prosthetic and orthotic teaching. Please refer to Appendix IV for an overview of the staffing of the school. There is still a strong expatriate presence in the faculty/staff. These individuals play the main leadership roles within the school. This is especially the case in the area of clinical leadership. The addition of Ron Altman (USA certified practitioner) has given the school a mentor and clinical leader that has made a very positive impact on the third year students. xii) Access to medical and other paramedical personnel. There seems to be an effort put forth to have the students exposed to other health professionals during the curriculum. This is especially so as it relates to

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physiotherapists and community workers. But, there is still a lack of exposure to medical related professionals and an absence of any real clinical team. xiii) Teaching materials Teaching materials exist but are not as comprehensive and detailed as is needed. This is also an observation in Mr. Mel Still’s report on CSPO (this report is available as a download from our download website). This is an issue at most schools worldwide and this is an area where there needs to be a strategy developed and in turn, ISPO play a role. xiv) Facilities such as classrooms, workshops, equipment, clinic areas. PLUS Student residence above clinic area. Overall the facilities are adequate but in general terms they are outdated or in need of repair or refurbishing. This comment applies to the overall lab environment besides the machines and equipment that exists. The lab spatial allocation and organization could be re-examined to improve it. It was also observed that there could be a better reinforcement of the health and safety procedures within the school environment. The condition of the student housing must be addressed. The existing condition is thoroughly detailed in Mel Still’s report and it is clear that a plan of action must be implemented. Overall, I would again point to the detailed overview that the Still’s Report provides to give guidance. Other questions or issues addressed with comments added: What assurances are there that a high standard of practical and clinical work is maintained? The quality assurance implemented by the school has had a very positive affect on this issue and facilitates a process whereby there is a continual “check” on all elements and processes that in the end assist in assuring a high standard. This process may seem “heavy” from the point of view of time, manpower, cost, etc., but from the inspector’s opinion it seems to be well worth the investment.

Use of components There use of components and materials is very limited and for the most part only entails ICRC componentry and polypropylene. Discussions focussed on the

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possibility of having other components introduced and having this financed by an external donor. Access to patients

The access to patients for the program’s curriculum is via the Calmette P&O Clinic. There seems to be enough of a patient load available now as compared to the past. Future strategies could still focus on ensuring a wider scope of pathological conditions for the students. It has also been recommended in the past that other clinic/hospital liaisons be investigated to widen the clinical exposure for the students. Financial The budgeting and financial operation is the responsibility of one staff member who is overseen in the United Kingdom via Cambodia Trust. The concern around the financial aspects relates directly to the long term sustainability of the school in terms of the external funding that is necessary to run the school operation and provide tuition costs (via scholarships or similar) to students. Currently, 20 to 24 of the 36 students are sponsored and there is a large expatriate cost. Examination process and results Board of Examiners:

Mary Scott, Cambodia Trust Joel Nininger, Board of Studies Dan Blocka and Bakht Sarwar, ISPO

Process: Each student presented two cases which encompassed either a trans femoral/knee disarticulation prosthesis and ankle foot orthosis or a trans tibial/ankle disarticulation prosthesis and knee ankle foot orthosis. The students had 20 minutes to present each case with 10 minutes for follow up questions. See Appendix V Results: The results for the examination were excellent with the students overall performing at a very high level on all aspects of the exam. The results of the exam are displayed in Appendix VII (not included as of yet). Comments/Observations: For the Education Chair, this was the best result observed in an ISPO related exam since his involvement began in 1998. Congratulations to all the students and the staff!

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CSPO does not have an overall comprehensive exam at the end of the three year curriculum. There are exams at the end of each module and at the end of the clinical placement. The ISPO Protocol for final examination was not implemented fully and the Education Chair takes full responsibility for this happening. Normally the ISPO process encompasses a comprehensive written exam with the option to add oral or other practical tests. ISPO should at least implement a comprehensive written exam for the next inspection date. Overall there seemed to be a fair allotment of patients to students for the exam. The process for patient allotment should be looked at again to ensure a fair distribution of patients with regard to their difficulty. Meeting with students and staff Meeting with students and staff were conducted. There is little to report from these meetings as the issues are dealt with elsewhere in this report. Overall there is a very positive environment at the school and all staff and students seem to work as a cohesive and productive unit. No major issues where raised outside of the other elements raised in this report. Meeting with Board of Studies The meeting with the Board of Studies took place at CSPO with most members present. The meeting encompassed the following components.

i) Introductions ii) How are Board members chosen and what are their roles iii) Future thoughts and considerations iv) Who are the stakeholders in the future -> national and international v) Questions for the ISPO representatives

The meeting was a positive discussion on many areas concerning the school and was constructive. Areas of this discussion will be brought forth in the Recommendations & Issues section of this report. Recommendations & Issues

a) It is recommended by the ISPO inspection team that CSPO be granted full Category II recognition for a 5-year period due to the excellent result of this inspection in all areas examined. The ISPO Inspection Team are unanimous in their opinion that this school is a clear leader in the region for the profession and an excellent role model to the other P&O schools in the world.

b) The documentation the school provided for the inspection process was

excellent and the most thorough seen by the Inspection Team. The quality assurance program implemented has had a very positive aspect in this regard.

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c) The expatriate presence is strong and adds very important elements to the

training process. The concern on the other hand is that eventually this leadership must be found in the national/regional staff. There must be a clear plan to ensure this takes place into the future. The Inspection Team sees this as a major challenge ahead for the school, especially in the area of clinical leadership and mentorship. This is not so much of a concern from the administrative and operation of the school as it is clear that Sisary Kheng has the potential to lead in this area. It is hopeful that with the proper professional experience and also the implementation of the upgrading program (developed with La Trobe University in Australia), that this will assist in the development of national and regional staff to be future leaders of the profession and school.

d) The medical/rehabilitation team has to be strengthened in the region and

within the presence of the school. This has been an issue over the years and the school leadership recognizes this weakness. There is no obvious solution to this in the short term but in the longer term this problem should be solved.

e) The government recognition of the profession and school needs to be

deepened for the long term in terms of having the ministries of education and health more involved and knowledgeable about the program and profession. It may be possible to improve these ties with more publicity and marketing related efforts. Any further government recognition will be a challenge as the government sees any financing as an issue.

f) There is a need to develop stronger ties to national academic institutions for

future stability and to facilitate proper recognition at the national and regional levels. This normally can transpose itself to a complementary recognition of the profession within the ministry of health.

g) It is recommended that the full ISPO examination protocol be implemented for

the final examination process. This issue was raised earlier in the report.

h) To widen the scope of components and materials utilized in order to facilitate a broader scope of options in terms of the P&O treatment protocol.

i) To plan for infrastructural upgrades/changes in the near future to deal with the

issues raised around machines, equipment, quality of lab space and so on. The need to improve the student living quarters is more immediate.

j) The curriculum should ensure a wider scope of pathologies being treated from

both a theoretical and practical point of view. This issue surfaced during the examination process when the examiners were told that certain areas being examined were not covered in the curriculum. One of these issues was the approach in orthotics as it relates to spasticity, which is an essential area to understand when such a high population of patients requiring orthoses. This could be accomplished by introducing into an existing course or new course, the presentation and discussion of various case studies related to P&O. There may be the ability to share various cases with other schools. This could be a role for ISPO to facilitate.

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k) The Inspection Team congratulates the school for taking a leadership role as

it relates to P&O education in the Asian region and encourages the school to continue this role and related activity. (see paper EC31.8.6)

l) The school has the potential to influence the development of rehabilitation

care in the country/region and also assist in the development of the profession from the aspect of encouraging graduates to set up private type practises or similar. With the way the country has and is evolving, it seems only a matter of time before the economy will be able to support this activity.

Conclusions The inspection team is clear in it’s support and recommendation to grant CSPO a 5 year term of recognition at the Category II level. The inspection team would like to acknowledge the CSPO team and students for the continued work, dedication, and leadership they have shown. The spirit and positive energy within the school is duly noted. We would also like to thank everyone for being such great hosts during the time of our visit. Dan Blocka Dr. Bakht Sarwar

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Appendices

Appendix I – METHOD OF INSPECTION & PROPOSED SCHEDULE

Draft Document for the CSPO Inspection – September 20 - 23, 2005

The current ISPO Category II Information Package will be used as the framework to ensure the competencies required to reach a Category II level of practitioner are met by each specific jurisdiction being evaluated. Therefore information throughout this whole process will be required as the specific prosthetic and orthotic school curriculum may be only part of the overall process. The description of the Professional Profile and the Learning Objectives/Competencies for a Category II professional that are sections 2 and 4 respectively in the ISPO Category II Information Package will also be used in the inspection process. They will be used as a template to ensure the primary academic and practical elements are encompassed in the program. Schedule for Inspection Tuesday September 20 and Friday September 23 Initial Discussion:

- Purpose of inspection - Clarify expectations - Finalize schedule

Tuesday am

- Tour of facility o Classrooms o Laboratories o Teaching resources o Students

- Overall background on CSPO - Presentation/clarification of items (i) to (iv) - Curriculum Issues - Presentation/clarification of items (v) to (vi) - Presentation/clarification of items (vii) to (xi) - Address specific requests from Inspection Team (if there are any – at the end

of Tuesday) - Meeting/discussion with faculty - Meeting/discussion with students - Meeting with other groups – ie: Board of Studies/Government, etc.. - Discussion of the topics outlined in the “Questions & Issues to address

section” - Other requests from inspection team - Finalize discussions - Other requests for more information/documentation if required - Clarification of what will take place after discussion

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The inspection will focus on following issues:

i) What are the entry requirements & minimal requirements for professional recognition? a. Entry requirements for the course at CSPO

i. What level of competency must someone have to enter CSPO

b. Are there minimal requirements for entry into the professional pathway to attain the competency level?

c. Is there a minimal academic qualification(s) required to practise.

ii) How is the course and candidates recognized? a. National recognition b. Education and health authorities c. Professional bodies/association

iii) Certification of course

a. Is the course certified or accredited by an outside body – government and/or professional?

b. Are there published guidelines/requirements for this c. Is a certificate of recognition given – if so, we should have a copy

iv) Permanency of course

a. What assurances are given that the course at CSPO is sustainable b. Financing of the program for the future? Budgetting (ie: student

costs?) c. Government recognition issues

v) Program/curriculum structure

a. Duration of overall curriculum/course (ie: start dates and end dates) b. How many intakes of students per year c. Listing of all courses d. Curriculum design or schematic e. Listing of program objectives/outcomes f. Hours and schedule of all courses

vi) Content of courses - list course in each category and provide the

following a. Theoretical subjects

i. Course description ii. Course outlines iii. Course goal & objectives iv. Marking schemes v. Examination/evaluation utilized

b. Clinical subjects

i. Course description ii. Course outlines

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iii. Course goal & objectives iv. Marking schemes v. Examination/evaluation utilized vi. Breakdown of devices fit in the practical subjects

1. How many are performed on live subjects/patients 2. If procedures are not implemented on live subjects

how are carried out

c. Workshop/lab subjects i. Course description ii. Course outlines iii. Course goal & objectives iv. Marking schemes v. Examination/evaluation utilized

vii) Teaching staff

a. Listing of all teaching staff full and part time b. Professional credentials held c. Short resume for each staff member

viii) Examination processes

a. Examination methods/protocols within the curriculum b. Are there any protocols/rules for testing and assessing academic

and practical areas

ix) Final examination / certification exams a. Is there a process for final examination upon exit of the program b. Who has the authority over this exam process c. Who composes/makes up the exam d. Is there a published protocol for putting on these exams e. When do they occur relative to the educational program

x) Internship/residency/work experience arrangements

a. Details of work experience(s) during the educational program b. Details of an internship/residency program if implemented

xi) Facilities such as classrooms, workshops, equipment, clinic areas

a. Overall layout of the facility b. Safety protocols/precautions

Other questions or issues to address:

- What assurances are there that a high standard of practical and clinical work is maintained.

- How are curriculum changes decided upon and implemented? - Component and material use in the program - Failure rates at CSPO - Access to patients - Financial - What is the level of training compared with other paramedical professionals?

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- What is the access to medical and other paramedical personnel for exposure to the students within the curriculum?

- Teaching materials - Employment prospects of graduates

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Appendix II – PREVIOUS ISPO INSPECTION REPORT

EB(EC)24.4.1 International Society for Prosthetic and Orthotics (ISPO) Cambodian School of Prosthetics and Orthotics (CSPO)

Triennial Inspection 16-21 September 2002

Introduction: The Cambodian School of Prosthetics and Orthotics was set up in 1993. The first intake of six students commenced studies in January 1994. There have been subsequent intakes of 12 students per year. The School is recognized for the training and education of Orthopaedic Technologist Cat-II by ISPO for the period of January 1999 to January 2002. Para 6 on page 17 of the Information Package of ISPO on Category II Professional-Orthopaedic Technologist under the title ISPO RECOGNITION OF CATEGORY II COURSES say that, “Maintenance of recognition requires a triennial inspection by ISPO.” For this purpose Dr. Bakht Sarwar visited CSPO, 16-21 September, as ISPO Inspector-cum-External examiner at the time of the final year examination and the following paragraphs summarize his report. Entry level to course: 10 years education or High School Baccalaureate Diploma or equivalent. However most of the students in present intake have 12 years of general education. The selection process includes entry examination and interview conducted by the Ministry Staff and Board of Studies under CSPO conditions. Content Of the course: The Course covers a wide range of theoretical subjects as well as workshop and clinical placements. Subjects covered include: - Anatomy, Physiology, pathology, Psychology, Material Science, Workshop Theory, Mathematics, Mechanics, Technical Drawing Management, Communication, Basic Computer Skills, Technical English Studies, Workshop Practice and Clinical Placement. The Clinical Practice covers almost all the prosthetics and Orthotics. Duration of Course: The course is of three years duration. There is 5000 hours available for theoretical subjects, practical work and clinical placements. Recognition of Course: The Ministry of Social Affairs Labour Vocational Training and Youth Rehabilitation award the National Diploma of Prosthetics Orthotics. Level of training of other paramedical professionals:

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Physiotherapist and nurses undertake diploma courses in Cambodia.

Teaching staff for theoretical subjects Teachers for the theoretical subjects are drawn from the expatriates, local staff and part time teachers from the other institutions. Staff for prosthetics and Orthotics teaching There are 05 Category I Prosthetists and Orthotists. All are expatriates provided by the Cambodian Trust. There are also 04 Assistant Lecturers (Category II Orthopaedic Technologists). The School is planning for the training of the local staff to get Category I status.

Examination protocol There are 11 modules and all the modules are examined by written and verbal examination under the jurisdiction of the CSPO. These examinations are run by CSPO with external examiners from NGOs (ICRC, Handicap International, American Red Cross, etc.). A board of examiners including ISPO external examiner conducted the final year examination. The preparation and conduct of this examination was good.

Standard of practical and clinical work The standard of practical and clinical work of the final year was examined in the final year ISPO examination. The practical work of 1st year and 2nd year was observed during the class work. In general it was of good standard. Failure rates All students have the opportunity to reappear in any examination they fail. This year all have passed their final examinations, although in previous years some required resits. One reason for this high pass rate this year may be due to selection procedures and the high quality of students entering the course. Access to patients There is somehow good supply of patients from the workshop run by the Cambodian Trust.

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Access to medical and other paramedical personnel Teaching materials There is access to paramedical personnel through Cambodian Trust and other International NGOs working in the field of rehabilitation. Teaching materials The CSPO manuals made for each module are currently being used. In addition there is a small library with books on the related subjects. There is good supply of handouts and teaching charts. Facilities such as classrooms, workshops, equipment, clinic areas There are three classrooms and three bench workshops with associated machine rooms and stores. The clinic areas are adequate for the purposes they are used for. There is a good supply of components and materials. Employment prospects of graduates So for all the graduates are employed by the International NGOs. None of them is employed in the public sector. Internship arrangements The School has no internship arrangements. Certification of course The diploma is certified by the Ministry of Social Affairs Labor Vocational and Youth Rehabilitation.

Permanency of course Presently it appears that the course is very well established by the Cambodian Trust. However one do not see the handing over of the school to the local authorities in the near future. RECOMMENDATIONS:

1. Possibilities of linkage between CSPO and orthopeadic/medical departments should be considered.

2. A weekly consultation clinic should be established during the clinical placement to

improve the clinical skills esp. the interaction with patients, assessment of the disability and prescription criteria.

3. Exposure to different materials and components during the course work should be

considered.

4. Cost calculation should be introduced and should be part of final year examination.

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5. Possibilities of clinical orthopeadics classes should be considered.

CONCLUSION: The Inspector recommended the re-accreditation of CSPO for the training and education of Orthopaedic technologists Category II for a period of three years after which the course should be re-inspected taking into accounts the recommendations outlined above. Dr. Bakht Sarwar 02 October 2002

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Appendix III

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Appendix IV – CSPO Faculty and Staffing

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Appendix V – Examination Protocol

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Appendix VI – National Diploma of Prosthetics & Orthotics

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