3.1. Problem identification and general needs assessment

The most important step is the first one, the general needs assessment (GNA). The goal of step 1 is to focus the curriculum, by defining the deficits in knowledge, attitude, or skills that currently exist in practitioners and the ideal approach to teaching and learning these objectives. When completed, the GNA makes a strong argument for the need for the curriculum and identifies potential educational research questions.

Research for this step can extend over many fields of endeavor: public health and epidemiology, health care systems, utilization and resources, emerging knowledge of disease, patient support groups, and educational theory and practice.
A well-researched step 1 impacts steps beyond the learner objectives by identifying educational methodologies, faculty development resources, potential funding resources, and opportunities for dissemination of the curriculum.
Identification and critical analysis of the health care problem that will be addressed by the curriculum requires substantial research to analyze what is currently being done by practitioners and educators, i.e., the current approach, and ideally what should be done by practitioners and educators to address the health care problem, i.e., the ideal approach. The general needs assessment is usually stated as the knowledge, attitude, and performance deficits that the curriculum will address.

3.2. Needs assessment of targeted learners

The general needs assessment is applied to targeted learners. What kind of doctor do we want to educate it depends mostly on social needs but it can reflect job opportunities, financial rewards and attitudes acquired during process of studding. Sometimes it is very difficult to make balance between these several needs. Needs can be obtained on different ways. It can be done through study of errors in practice. It is very difficult to design curriculum which will fully meet the needs of society and students. Following picture present the relation between needs of different subjects.

Expectations of society from graduate students are view from one perspective. For example, according to the European Qualifications Framework graduate students should possess following performances:

• The descriptors
• Knowledge and understanding
• Application of knowledge and understanding
• Ability to making judgments
• Ability to communicate
• Learning skills
• Level depending on the cycle

If we ask students what they expect from their knowledge after graduation we will probably get another list of expectations.
Curriculum of medical faculties must be designed on the way which can provide performances after the student graduation asked from society but from student as well.

At the base of the general needs and needs of targeted learners should be made essential documents for every institution, the mission statement. Mission statement can include just generalized reasons for existing of institution, but it can be more concrete and include several aspects of student’s knowledge like: theoretical knowledge, skills, performances etc.
The mission statement should partly give sort of picture, what kind of graduated student do we want. Involvement of the key subjects in process of curriculum development should be from the early stages of process of curriculum development, and one of the first steps is creation of mission statement of institution. All stakeholders of institution should be included in this process, and they all should give their view of the reasons why the institution exists.
In the process of defining of mission statement for medical institutions, it is recommendable to include all stakeholders such as: representatives of ministries of health, health care institutions accrediting agencies and scholarly societies and ministries of education. Stakeholders will ensure: financial, political and all other support which mission ask for in the process of implementation of new one or reformed curriculum. Some authors propose strong relationship with other educational institutions that are similar in certain aspects with the institution which try to define its mission.

Mission of B&H medical faculties covers following areas:

I Teaching
II Research
III Medical services and health care
IV Role in society health care

3.3. Goals and objectives

Institution should define overall goals and aims for the curriculum. Specific measurable knowledge, skill/ performance, attitude, and process objectives should be stated for the curriculum.
Learning goals and outputs for every course and subject should be compatible with mission of institution. It means that achieving of learning goals of different subjects and courses will lead to reaching mission of institution at the end of student studding process. Planning of new curriculum and reform of old one asks for defining of philosophy which is ` behind ` the curriculum and all its elements. Learning goal and outputs should also determinate the educational philosophy and institutional culture. So, mission of institution, educational philosophy and institutional culture are key elements of educational settings necessary for curriculum implementation.

An aim indicates the direction or orientation of a course in terms of its content. An aim is written in terms of level, teaching intentions and management of learning. The aims of the course encapsulate the purpose of the course and what the institution trying to do in providing the course. Aims are therefore more about teaching and the management of learning.

Learning Outcome is an expression of what a student will demonstrate on the successful completion of a course. Learning outcomes are related to the level of the learning; indicate the intended gain in knowledge and skills that a typical student will achieve and should be capable of being assessed. Learning outcomes are more about the learning that is actually to be achieved by the learner. Outcomes ten formulated as competences. The outcomes are coherent with the educational vision. These objectives make it also clear to the student what may be expected of the course.

The aims and learning outcomes of a course should determine the choice of teaching processes through which the module is presented. The teaching processes should be matched to the processes required of the student in attaining the intended learning outcomes of the course. Since a course will normally have several intended outcomes, different components of the course will be suited to different teaching and learning processes, and such a course should be presented through a variety of appropriate methods.

(Educational) objectives are the end qualifications that are aimed to be reached by the student at the end of the study program. Curriculum is in continuous process of tuning objectives to the expectations of external actors (stakeholders) and internal actors (clients)

Tuning of curriculum and objectives clarifies which course subjects or which groups of subjects contribute to the different objectives.

• It is an instrument to make sound decisions for the learning environment.
• It is an instrument for evaluating subjects reliably.
• Students can derive from the objectives what they may expect from a study program; the list of objectives guides their studies.

CATHALOGUE OF LEARNING SKILLS AND OBJECTIVES

Very important step is identification of attributes expected of medical graduates. Once these attributes are identified, educators must translate them into meaningful learning objectives.
It is recommendable that every medical school has a catalogue of skills and knowledge, the document where all the theoretical and practical knowledge which student should have after graduation is listed. This document is based on mission statement of institution and it is derived from the learning goals and outputs of all courses inside curriculum.

3.4. Educational strategies

It is necessary to make a plan how to maximize the impact of the curriculum, which content should be included, how content should be organized and with which educational methods, how elements of curriculum should communicate, what kind of educational environment and climate should be developed. Content which is included must provide to student critical thinking. It must be selected and organized on the way to initiate critical approach to facts and development skill of information retrieval.
Document with the objectives, should be prepared in advance. Content of certain courses should provide better understanding of other subject, for example anatomy and physiology, radiology and anatomy etc. Position of each course is one of the aspects which should be analyzed. Mostly at the first study years basic sciences are taught and they provide continuation of studying with clinical subjects. Some models of curricula prescribe modules as organizational unit which includes knowledge starting from basic science and anatomy and physiology till patho-physiology, clinical diagnostic and treatment. New trends in modern education show signs of introducing an early contact of students and patients in the curriculum, and thus courses such as introduction in clinical practice have among the others the best possible preparation of medical students for studying clinical subjects etc.

Some possible educational strategies:

Student centered/ teacher centered
Student centered strategy ask for active role of student in process of definition of curriculum, decision about learning methodology and decision what and when they will study. Second strategy is based on teacher decisions what, when and how will certain subject be studied.

Problem solving/ information gathering
Problem solving strategy is based on student acquiring of knowledge through process of clinical problem solving. Information gathering is a strategy based on student presentation of gathered information.

Integrated multidisciplinary approach
This strategy is based on integration of different disciplines. Mostly integration is made around certain organ systems. Basic sciences, preclinical and clinical subjects are integrated around the organ system which they studied.

Community based/ hospital based
Community based teaching is educational strategy based on studying in community health centers, while in hospital based strategy educational process is based on hospitals which represent teaching base for faculty.

Elective/ standard
In elective strategy studying process is organized on the way that all students have the same core curriculum while they choose certain aspects which they want to study more deeply through elective courses. In standard curriculum all students have same curriculum without possibility to choose elective subjects.

Systematic planned/ opportunistic
In systematic approach teaching and learning experience are planned. In opportunistic approach student follow the experience of departmental doctor as it is.

3.5. Implementation

A plan for implementation, including timelines and resources required, should be created. A plan for faculty development is made to assure consistent implementation.

Management of curriculum implementation
Clear responsibility of certain bodies, comities and individuals should be one of key elements in the process of curriculum implementation. Role of the students in process of curriculum management should be clearly defined. The committee for coordination among courses in order to synchronize objectives of courses and overall curriculum should be established. Clear feedback on customer requests should be defined.

Teaching environment
Very important aspect of successful implementation of curriculum is teaching environment and fact whether the atmosphere inside the institution is encouraging for the people with ideas, initiatives and cooperation among students. It is desirable to establish a sort of “department of curriculum development”. The role of this department should be strengthening and expanding of faculty and curriculum development programs at the medical school and its clinical affiliates, with the purpose of enriching and advancing the school's educational mission. It should play a key role in the educational activities of the medical school, it works in collaboration with faculty to design, implement, and assess new courses, innovative teaching methods, and distance learning and educational technology initiatives. This department should provide programs in numerous aspects of classroom and clinical teaching, so that faculty can expand their knowledge base in education and enhance their teaching skills; develops workshops and seminars upon faculty request; assists individual faculty who would like to improve their teaching; and provides faculty with consultation on and assistance with projects in medical education

3.6. Evaluation and feedback

Evaluation of curriculum presents the final stage inside cyclic process of improvement and development of curriculum.
Without evaluation procedure it would be hard to imagine monitoring of institution progress toward desired needs. This process is necessary to provide the evidences that institution made a step in the right direction, as well as useful information to stakeholders. It helps in the process of identification of problems inside curriculum and institution, solving of problems and redesigning of certain aspects of curriculum. Evaluation can be performed as short-term and long-term evaluation. Short-term evaluation has a role of “friendly” criticism, while the long term evaluation is a crucial one, with much deeper impact. Department for quality assurance is usually in charge for conducting of such procedures and it is up to them to decide about many aspects of this process.
Evaluation of curriculum can be made through evaluation of many different aspects as:

• Psychological and interpersonal skill
• Continuing learning
• Professional satisfaction
• Practice behavior
• Educational achievement and cognitive development
• Institutional issues
• Student passing rates
• Making of clinical mistakes
• Clinical problem solving
• Educational cost per student
• Cost efficiency of graduates as practitioners

It is very important to carefully define the appropriate time for evaluation for each of these areas as well as the methods for its measuring. Evaluation will only have full meaning if it is followed by action in order to improve areas which are estimated as weak points of curriculum. This action is obligatory for relevant bodies and management structures and should be described precisely inside document policy agreement.