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The latter theory, sur mesure , identified with the constructivist paradigm, of a more qualitative nature, placed the evaluator in a position of listening to the political arena, seeking greater utilization of the results through the permanent involvement of the various players influencing the decision-making process. According to Chen , who formulated the concept of "theory-driven evaluation", it is crucial to reconcile quantitative and qualitative analytical techniques, which are not conflicting, rather constituting different possibilities available to evaluators to deal with the specificity of the problems entrusted to them.
This focus is becoming a consensus amongst the various institutionalization models studied. Thus, one already notes in the Canadian guidelines from that evaluations were to be designed with multiple lines of evidence, including carefully selected quantitative and qualitative data McQueen, In Switzerland, with a political structure of the typically intensive direct democratic participation type, data from evaluations are used extensively for consensus-building at the federal and canton level to shed light on problems and foster solutions, employing multiple approaches: "more positivist-more constructivist; quantitative-qualitative; distant-participant; prospective-retrospective" Bussmann, Contrary to this intensive use of evaluation as reported by Switzerland, a preliminary inventory of the first five years of the French governmental ruling presented by Perret showed that only 17 projects were analyzed by the CSE, while Weill pointed out that health policies were not amongst even this small group.
On the positive side, Perret identified the open nature of discussions within evaluation spheres, allowing for a broad grasp of the evaluation issue and its results by political players, although the effects on the decision-making process were insufficient. Leca , chairman of the CSE, is somewhat skeptical of ruling, noting that "evaluation appears to be a sacred cow" , where despite the lofty inauguration of the CSE including even a seat for the President of the French Republic , interest waned in submitting projects during the period from to with 10, 7, 6, 4, 1, and 0 projects per year, respectively.
Analyzing the institutional "import-export" flow of administrative reforms or modernization schemes in France, Rouban found that they have always functioned as loans or adaptations of organizational formats originating either from abroad or from the private sector. Resistance to evaluation, or ascribing to it what might appear to be a minor role, might be better explained by the fact that evaluation is not limited to a merely administrative adaptation.
It challenges the primacy of decision-making in the hands of public employees to foster intervention by diverse players, including representatives of political pressure groups, to change the work of the public sector, as in the case of the United States. The author emphasizes the importance of evaluation as a possibility for solving the historical impasse of the bicephalous system President versus Congress in US public administration through administrative and budget control accountability , which for years impeded reforms in US democracy.
Thus the GAO, in its capacity as an auditing and evaluating agency with a pedagogical mandate, is symbolic of the capacity to give Congress a pouvoir de bourse , situating itself at the crossroads between the two branches of government. Taking advantage of program-based cost structure, clearly identified on the budget and policy levels, evaluation has acted to counterbalance the separation of powers, regulating the political game between various players. While the author recognizes that evaluation cannot be done without institutionalization training of top personnel, adequate organization, and financial management , as shown by the experiences discussed herein, evaluation cannot turn politics into economics.
The success of the United States is partially due to a public administration rooted in the acknowledgment of citizens' rights to control the details of public activity and morals.
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Thus, without pretending to turn the "democratic scene into statistical democracy", which would destroy the principle of imputation, in order for evaluation to emerge from its modest space of management control to achieve a general recomposition of relations between administration and politics, it presumes a response to the inquiry into the form of democracy conceived for the French political system Rouban, Chronology of sectorial evaluation in health Table 2.
The perinatal program implemented in the s was a milestone in sectorial institutionalization, illustrating the relations between decision-making and technoscientific knowledge generated by evaluative research. According to Chapalain a , analysis and evaluation methodology was used for the first time in public health at the national level. This policy was based on PPBS, a methodological legacy of the US defense used in renewing public administration and institutionalized evaluation practices mentioned above. On the other hand, it did not involve the same US ambitions of maximizing the expected benefits as a function of costs, incorporating from the beginning the critical view of American theoreticians who in the late s called attention to the importance of replacing the "optimization" of public policy results with the search for a "satisfactory nature" in the improvement of this same policy.
In addition, they conceived of and provided an excellent exercise in their role as pilot committee, defined by them as a group activity facilitating the work of the commanditaire in turning a vague question into the object of research, accompanying its construction and providing technical support to the researchers in their methodological and operational options. Its objective was to summarize scientific data and conduct studies prior to the dissemination of technological innovations, thereby helping improve the sectorial institutionalization model. In , the conclusions from the Report by the Ministry of Health emphasized the deficiencies in the evaluation of medical technology, with Cedit appearing as the only available specialized agency in France.
However, I feel that two intervening factors contributed to push forward and implement the report's recommendations. The creation of Andem in with the autonomy recommended in the report fostered the dissemination of evidence-based knowledge in medical practice and helped define methods for technological evaluation.
Evaluation of medical technologies has formal status as a national project: The emphasis on technology assessment must be placed in the wider context of the French government's concern about lack of evaluation of public programs in general during a time of economic difficulties. The need to assess public policy and programs was indicated by several reports as a much-needed goal Weill, The field of public health was enhanced through the Special Committee for Research in Prevention and Evaluation, created by Inserm, originally as an ad hoc committee, with funds coming from the national health insurance system.
This committee has been an important catalyst, since epidemiologists, economists, and social scientists are now much more involved than before in evaluation projects Weill, It was an attempt to move from an administrative type of logic to one of opportunity oriented by contractualization Guers-Guilhot, and to build a "new public health", not only the reproduction of the central model, demanding the adaptation of intervention instruments consistent with local needs Henrard, The law provides for "the need for evaluation, respect for patients' rights, and the concept of universal health care.
Evaluation, an important yet undefined concept, has become through this law a leading channel for health care regulation, management and planning in France" Weill, A study by Michel et al. In order to implement this new sectorial evaluation policy, the legislation provides for the creation of two new mechanisms:.
Interdisciplinary teams 2 hospital physicians, 1 clinician, 1 sage-femme , 1 hospital director, 2 biomedical engineers, and 2 professionals representing the Andem , named by the regional prefects, commissioned to provide the necessary methodological support to the local level, where each public or private hospital should evaluate its activity in delivering quality care. These committees, not being permanent organizations and with no human resources or budgets of their own, leave doubts as to their efficacy.
Andem remains as support for the entire system, since it is in charge of validating the methods used in the planning process Weill, Commissioned to function as a consulting body for issues related to the new hospital mission of evaluating care, this broad responsibility involves defining adequate and well-adapted methods for evaluating services as part of policies, under the objectives of public health and system performance at the local, regional, and national levels.
In describing this new structure, Weill was concerned with the fact that its staff was limited at the time to one public health physician as a permanent member. The unit's main goal in the first two-year period was to consecrate the mise-en-place of a quality assurance policy, with actual compliance by the hospital system, in which evaluation was seen as one of the fundamental instruments.
The agency currently has a staff of four full-time professionals and a technical board made up of physicians and nurses with a small weekly time allotment, allowing for the implementation of the bureau and its initial proposal. Authorizations for initial and on-going functioning of services remain under the bureau, which is also in charge of constructing the evaluation model for monitoring the set of new measures as prevailing public health policy. One question demanding an immediate answer and summarizing this level's concern is how to evaluate the new territorial organization of health care.
These mandatory medical guidelines were drafted by the Andem for out-patient care, bolstering the logic of a medicine based on scientific evidence Pouvourville, Another French author Geffroy, had already identified the combination of evaluation and regulation distinguishing between but not opposing the domains of verification and evaluation, where the latter allowed for the validity of references for regulation as the only approach capable of reconciling ethics, quality of care, and economics. The following phenomena were already observed:. The Bureau for Health Evaluation and Economics of the DGS, established in but only actually implemented in , is in charge of defining the policy objectives for evaluation of medical practices, with the broader challenge of institutionalizing the legal, financial, and organizational aspects of evaluation in the health field Weill, It fell to this ministerial unit to conclude the regulatory framework for health reform in relation to the generalization and expansion of evaluation mechanisms developed experimentally by the Bureau for Hospital Administration.
It is interesting to highlight that the bureau was concerned with maintaining the clear distinction between inspection and evaluation, despite the discourse of the auditing bodies being oriented increasingly towards evaluation of results. Illustrating this issue, the physicians in charge of accreditation were not inspectors but visiting physicians, acting directly in hospital care. What remains to be decided, where irregularities are found, is how they articulate with the Public Inspection area.
The relationship between different bodies involved in health evaluation can be illustrated by the National Program for the Prevention of Breast Cancer, whose operational responsibility and funding come from the national health insurance system CNAMTS.
In short, the role of the bureau appears to concentrate essentially on issues proper to institutionalization, i. They are consistent with the stance taken by Geffroy : following the failure of accounting cost reduction, only regulation based on evaluation would provide legitimacy for cost reduction, beyond a mere rationing to allow for an increase in quality of care. Going beyond the limits of treatment practices and protocols to encompass organizational practices focusing on the solution of problems at the population level, the main thrusts are the following:.
Administrative and Scientific Councils were to share technical and financial responsibilities. A college of accreditation and a reseau national et local d'experts participate in the ANAES missions. Members of the college may be remunerated, while the wording does not mention this point for the reseau. Before contextualizing the French trend in the international scenario I should reiterate my justification for having used an integrated approach to the evaluation of programs and policies, in some cases involving medical care practices and technologies intrinsically related to them.
Although I agree that these dimensions can be treated separately, whenever analyzing the effectiveness of public health interventions a systemic conceptual framework is necessary to understand these dimensions as observation units necessarily linked to the evaluation process. Thus, a change in a population's state of health cannot be limited to that of an individual, for whom an evaluation of the clinical efficacy of medical practices and technologies may be sufficient.
It requires organized programmatic action, demanding collective choices proper to the field of public policies. Meanwhile, the implementation of a program derives from the evolution of available practices, which in turn are influenced by the development of medical technologies, organizational structures, and political priorities formulated for a collective body Hartz et al. In the case of France, this relationship can be illustrated by the evaluation of the breast cancer screening program formulated as a government policy, involving as crucial issues for collective intervention the strengthening of professional organization of radiologists and the multiplication of medical tests using types of equipment with varying degrees of performance Gremy et al.
Focusing on the international context, the first common denominator one finds in the objectives and structural and practical characteristics of evaluation is that it becomes imperative considering the uncertainty encompassing health intervention and the results observed in individuals, a phenomenon that increases as one moves to objectives at the population level. Evaluation thus emerges as the best way to obtain information on the efficacy of a health system Contandriopoulos et al. Considering the importance of cost control in medical care and the worldwide crisis in social security systems, we are not surprised that the health sector was among the first to benefit from the PPBS logic, as in the case of the RAND Research and Development Corporation, the result of an American strategic research project during World War II, which in launched its Health Science Program still one of the most important investments in civilian research when Medicare and Medicaid were created Gerbaud, The GAO led a study on evaluations performed in the fiscal period, a sort of meta-evaluation on the work of the various levels of the Public Health Services Program Evaluation, concluding that the evaluations had been insufficient as a source of information for Congress.
Another more recent report GAO, deals with an evaluation of the decentralization of grants, concluding in favor of greater flexibility in the frequency of reports required of the States for them to concentrate on results. Congress only becomes more prescriptive in cases involving inadequate information systems on funded programs.
According to Myers , while the United States and Canada have their specificities, they have evolved under the same Continuous Quality Improvement model, meaning that evaluators incorporate scientifically credible indicators reflecting patient satisfaction. This and other changes in evaluative practices speak in favor of plurality as the rallying cry for institutionalization models. Pettigrew , in England, observes great interest both in experimental models, extrapolation of clinical trials, and the American theories of "empowerment and democratic evaluation" inspiring evaluators engaged at the regional or local level.
Cobatoff summarized the latter's critical reaction to the former: "how could the author suppose The Simad proved to be a new intervention modality, evaluated in a pilot study incorporating gaps in prior knowledge, demonstrating that the "program evaluation methods are only better in the sense that they are better adapted to policy-making situations that they are attempting to influence" Cobatoff, The fact that one defends the importance of adjusting research lines to planned utilization of results does not mean that the research means nothing more than precise and immediate application.
On the contrary, evaluative research should be encouraged on an on-going basis, since its "timing" cannot be determined by the urgency of the decision. The main objective of the National Health Forum created recently by the Canadian government with participation by experts from the field is to understand how research can help the government develop consensuses on the means to maintain the system's efficiency while respecting les temps de la recherche Champagne, A pathway worth exploring was suggested by Pouvourville , i.
While France institutionalizes evaluation as a mechanism for regulating the health system under the same origins described internationally, it is structured on the basis of a biomedical model i. Lastly, please ensure your credit card is authorized to make international payments if you are abroad. You may want to contact your financial institution or credit card provider to authorize these types of transactions.
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