Application for 2011 University of California Larry L



Application for 2011 University of California Larry L. Sautter Award for

Innovation in Information Technology

Date

May 20, 2011

Project Title

School of Medicine – Admissions System

University of California Davis Health System

Submitted by

Dan Cotton, Education Technology and Application Development Manager

Michael Minear, CHCIO, Chief Information Officer, UC Davis Health System

Content Contributors:

Mark Henderson MD - Associate Dean, Admissions and Outreach

Gurmeet Rai – Chief Administrative Officer

Francis Sousa - Faculty Admissions Specialist

Project Leaders and Team Members

Executive Leadership

Michael Minear, Chief Information Officer

Ann Bonham PhD – former Executive Associate Dean, SOM – Ann is now the Chief Scientific Officer for the Association of American Medical Colleges (AAMC)

Fred Meyers, MD Executive Associate Dean, SOM

Mark Henderson, MD - Associate Dean, Admissions and Outreach

Jim Nuovo, MD – Associate Dean, Student Affairs and Graduate Medical Education

Information Technology

Daniel Cotton – Application Development Manager

Mark Carroll – Assistant Director, Health Informatics Graduate Program

Jason Dohrn – Systems Analyst

Alisa Hsiu – Database Administrator

Shang Wei – Application Developer

Benjamin Hee – Application Developer

Sunitha Venteru – Application Developer

SOM Office of Medical Education Leadership

Gurmeet Rai – Chief Administrative Officer

Edward Dagang – Admissions Director

John Drummer – Curriculum Manager

Project Summary

In response to many challenges in the approach the UC Davis School of Medicine (SOM) used to support its annual admissions process; the SOM and the UC Davis Health System Information Technology division (IT) partnered to fundamentally redesign the SOM admissions process. An innovative approach to link process improvement methodology with a modified agile software development process was created.

The redesign of the school’s admissions process has now completed its third year of design. Sixty nine new processes have been defined and are supported by modern software. The use of paper has been fully eliminated.

Because of the new processes and software, the SOM has reduced its annual admissions cycle time by five months and has is much more competitive in recruitment of new medical students. According to the leadership, faculty, staff, and students of the SOM; the project was transformative to the admissions process and the SOM on many levels.

Project Description

Context

Similar to most organizations, the processes and support systems used by the SOM evolved over many years and were not serving the SOM well.

• Work was defined over many years, but in hindsight there was no evidence of an overall design: people and departments across the SOM created worked on their own and often failed to link what one group did with other departments of tasks.

• There had never been a full analysis of best practice and how that should impact the design of SOM processes and the daily work of faculty and staff.

• Software was applied to the SOM processes in a scattered non-integrated fashion without a core strategy or architecture, especially the common use of microcomputer based tools such as MS Excel and Access. Everyone in the SOM could quickly create data islands with these tools, and literally tens of thousands of local spreadsheets and databases were created.

• While partial automation had been created there was still massive use of paper forms and files.

By 2007 it was clear to everyone in the SOM that the admissions process was causing major problems. The annual admissions cycle to so many months it was almost a constant throughout the year. The UC Davis SOM took so long to sort through candidates and prepare offers to desirable candidates that by the time candidates received the UC Davis offer: they had often already accepted admission to another medical school – sometimes months earlier.

The long time to offer admissions made it difficult to optimally prepare for the start of each fall semester, and the candidate records had to be manually converted to first year student records. The large amounts of paper, islands of data, and slow processes were taking their toll on the entire school. It was clear a totally new approach was needed. The long held practice of making minor and non-integrated change, and adding poorly designed niche software was only making things worse.

The leadership of the SOM decided they had no choice but to seek a way to dramatically improve the admissions and associated support processes to avert a crisis. In December 2007 a project team was created to create dramatic change and improvements. The team was comprised of the office of medical education leadership and staff and information technology management and staff.

The Health System CIO, Mike Minear suggested that no additional software be installed or modified until the organization assessed the overall processes involved with student admissions and education. A detailed process assessment guided by a process improvement methodology would create the required break from the past.

This approach was strongly supported by Ann Bonham, the Executive Associate Dean for the SOM. Bonham and Minear jointly sponsored the process improvement team and provided ongoing support and encouragement.

Process Improvement Methodology

A simplified version of the Rummler-Brache process improvement methodology was used. This methodology guides an in-depth analysis of all processes, roles, and tasks. Some of the common outcomes expected when this methodology is used include;

▪ “Forge a stronger link between strategy and process redesign

▪ Install a top-to-bottom measurement system that provides a foundation for continuous improvement and growth

▪ Overcome the common pitfalls in process redesign efforts

▪ Implement the significant changes that result from Process Improvement projects

▪ Develop a customer-focused, participative, low-conflict, accountability-based Culture” [1]

The SOM challenges were well suited to this methodology. The challenge of improving the admissions process and associated student support processes was identified by SOM leadership as a primary goal. Any solutions could only be achieved by all elements of the SOM working together to drive dramatic change. Material improvements required full alignment of the SOM’s leadership, teams, and people. The teams taking on the required changes were empowered to address any issue and scope in the SOM’s processes and daily work. An approach with straightforward tools was needed to engage and support all elements of the SOM.

How the UCD SOM and IT applied the Rummler-Brache Methodology

The first step was to fully assess and document the IS process (current state). This involves creating an in-depth understanding of how work is done at the current time. Highly detailed process maps were created to document the flow of work. A unique feature of Rummler-Brache is to create two dimensional process maps. The first dimension is the flow of tasks, the second dimension are horizontal swim lanes for each department or sub group that performs the work. This approach ensures clarity on what work is done and who does it. The UC Davis SOM project added a third dimension; what data is created at each step in the process and how it is created and stored (such as paper forms, application software, excel spreadsheets, and so on).

In addition to process maps, defining the IS process includes documenting forms, data models, policies and procedures, training manuals, web sites utilized, and all other aspects of how work is currently done. Creating the IS process is often humbling; with all of the problems in the current process defined and highlighted. When the final SOM IS process was printed on large paper to share, it was over 20 feet long.

The following small element of the SOM IS process shows the flow of work, overlaid into the ‘swim lanes’ indicating what team or function did the work. This example is just a fraction of the overall IS process maps created.

[pic]

Part of the SOM SHOULD process map

A common tendency is to jump to creating the new process or writing software with only partial analysis of the IS process. Jumping ahead creates many problems and typically results in making the same mistakes made in the past, creating partial or niche solutions that often only make things worse. Only after the IS process is complete is the process improvement team ready to move to the next step – creating the SHOULD process (optimal future state). The detailed knowledge gained in creating the IS process is critical to create the optimal SHOULD process. The SHOULD is a proactive design from a clean slate.

The SOM teams engaged all staff and faculty who supported the admissions and associated processes to create the SHOULD process. From the most senior Dean to front line clerical staff, everyone was engaged to design the optimal way things should be done. It is very challenging to do this work, as past ways of doing things, preconceived notions, and previous barriers or problems that existed (and typically still exists at the time the SHOULD process is being created) had to be ignored. Everyone was challenged to think out of the box and create as radical of changes as required to create breakthrough change.

The analysis of the SOM IS process started in January 2008 and concluded in early April 2008, and included participation from all twelve SOM Office of Medical Education units over a span of two and a half months. The scope of the analysis of the processes used to support applicants applying to the SOM, through the four years of medical school teaching, and through graduation.

The teams averaged four meetings a day with key stakeholders, subject matter experts and unit managers. Components of the school’s current state were captured in three dimensional process models that included work flow, the unit/staff doing the work, and how any data was created (paper or software).

The actual staff or faculty that performed the daily work of the SOM was very involved with the process and task assessments. The descriptions included step-by-step text descriptions, defining the flow of work and data, the people & teams doing the work, detailed functional aspects of each task, any behavioral or time sensitive elements, and any software or paper forms used in the work. Process models were created using MS Visio. IT staff facilitated many of these discussions and documented findings.

The IS processes analyzed included admissions, Registrar functions, 4th year scheduling, course management, financial aid, and others. In total sixty nine process models were defined and created. As processes were documented, supporting and sample documents were collected and evaluated. Photographs were taken of the various filing cabinets and floor space that was needed to store and secure the paper documents.

Documents used throughout the IS process were analyzed and counted. In one example, over 17,000 Excel documents were counted stored on the departmental server. In almost all cases, every document was a duplication of effort since there was no common software or method to share access.

For each major process step the method of creating and storing data was also defined (paper, excel, database). A pie graph was created and inserted into the process map highlight to the many types of data creation methods utilized by the SOM. The pie graphs were useful as they drew attention to the many methods and technologies used in the IS process; most of which did not share data and were not integrated. The more colors in the pie chart indicated lower data integration and the presence of duplication and re-work.

[pic]

Large number of data creation and storage methods in the SOM IS process

American Medical College Application Service (AMCAS) Dataset

A key aspect of managing applications to American medical schools is the American Medical College Application Service (AMCAS). AMCAS is a non-profit centralized application processing service for medical schools. All applications fill out their applications to medical school on the AMCAS website and designate which medical schools they are applying to. AMCAS then transmits the data securely to the medical schools as directed. Using this process candidates don’t actually apply directly to a medical school such as UC Davis but AMCAS. The AMCAS applicant digital content is the clear starting point for any medical school admissions process.

In the IS process, UC Davis SOM literally printed the digital AMCAS data, manually re-entered some of this data, and stored and moved the printed AMCAS application with all the other paper created. A key observation for the UC Davis SOM was that the AMCAS data could have formed the basis of an applicant record with standardized and accurate data; the inability to re-use this data in its digital form became a metaphor for the duplication and rework in the SOM IS process.

|Applicant data collected by AMCAS and shared with Medical Schools |

|1 |Identifying Information |Demographic summary |

|2 |Schools Attended |High school and colleges |

|3 |Biographic Information |Citizenship, language spoken, ethnicity and race, criminal convictions |

|4 |Course Work |Grades and credits about every course taken |

|5 |Work / Activities |Any work, extracurricular activities, awards, honors, and publications |

|6 |Letters of Evaluation |Letters and contact information |

|7 |Medical Schools |Designate the medical schools applicant applied to |

|8 |Personal Statement |Personal essay, hardships, or experiences |

|9 |Standardized tests |Review MCAT and GRE scores |

Summary of AMCAS dataset [2]

In late April 2008, the findings were presented to the SOM senior leadership. The details of the presentation highlighted the many duplicate processes, lack of data integration and poowr application software interoperability. It highlighted tangible cost savings and focused on the original goal of collecting data in an organized, structured fashion which would allow leaders to perform longitudinal analysis of both student and curriculum; and perform work much faster than in the past.

The presentation resulted in the SOM leadership supporting the next phase of the process – the creation of the “SHOULD” processes for each of the SOM units. The SOM admissions process was chosen to be the first unit and process to undergo this deeper analysis.

The IT team worked with the Associate Dean, Admissions & Outreach Dr. Mark Henderson, the Admissions Director Ed Dagang, and the Chief Administrative Officer Gurmeet Rai to develop the SHOULD admissions process. The team created the new admissions process from May 2008 through June 2008, and when completed started software development in late June 2008.

[pic]

Dramatic Reduction of type numbers of data collection and storage methods

Result of the New Process and Software

The UC Davis School of Medicine admissions and IT teams achieved their goal of eliminating 100% of the paper in the admissions process, improving the productivity of staff, responding more quickly to applicant inquiries, and in capturing all the data and information electronically for later analysis and dash boarding.

The next admissions cycle – the 2010 year was started with complete software functionality developed during the 2009 admissions cycle and the experience of using the SHOULD process fully for one cycle.

Goals were set to dramatically improve the cycle time for the 2010 year; with one indicator of success to make admissions offers to candidates on October 15th, the first day medical schools can make admission offers to applicants; something that had not done in over 20 years at UC Davis. During the 2010 admissions cycle with offer to 13 applicants were made October 15, 2009. In the 2011 admissions cycle the school made 25 offers on October 15, 2010.

For the 2011 year, new process and software upgrades were made to support a new methodology for interviewing medical school applicants, called the Multi Mini Interview (MMI). The teams started collaboration in January 2010 on the “SHOULD” process for the MMI process and delivered the required modifications to the software by May 2010.

With the addition of the MMI interview process, a new, much more detailed, richer and complicated interview system was added, placing the UC Davis SOM as one of the vanguard schools modeling the AAMC’s vision of optimal and ‘holistic’ approach to admissions. Rather than primarily rely on MCAT test scores and short traditional interviews, the MMI process puts candidates through a rigorous full day series of interviews and simulations. Simulated clinic exam rooms, actor patients, and other real life scenarios to assess how candidates perform. The output from these more intense interviews are thought to better assess which candidates will succeed in medical school, residency training, and ultimately as physicians.

[pic]

Interview Circuit for the MMI Interview Process

Also, applicants are now made aware of their application status within 2 weeks of the interview; a dramatic and remarkable improvement over previous years (and previous versions of the admissions process).

The new online software application puts real time data at the fingertips of those administering the admissions process. Real time data is available in the form of dashboards for each step of the admissions process. Administrators are able to view the status of screening, interviews, selection and other evaluation steps of the applicants in real time and make changes as necessary to keep the process flowing efficiently and effectively. This ‘real time’ window into the admissions process has had a “transformative” impact on the entire admissions process for the school.

The experiences and the success of the admissions system has led to similar efforts for other elements of the SOM’s overall processes; 4th year course scheduling, the student information system, and the curriculum database. In each case dramatic improvements were made by applying knowledge and information gleaned from the “IS” process and developing a well-designed and integrated “SHOULD” process supported by new or modified custom software.

The project has been very different than any other approach attempted at the UC Davis Health System. The outcome of the project has been successful beyond the wildest dreams of all involved. This approach to obsolete work processes and non-integrated technology is being used with other challenges at the UC Davis Health System.

Approach to Software Development and Technology Used

Agile Software Development

The Health System IT division used a modified version of the agile software development methodology to synchronize with the Rummler-Brache process improvement methodology.

“Agile software development is a group of software development methodologies based on iterative and incremental development, where requirements and solutions evolve through collaboration between self-organizing, cross-functional teams. The Agile Manifesto introduced the term in 2001.”[3] The core attributes of the agile software development approach were perfect for the SOM project; focus on customer’s needs, continuous delivery of software, partnership with people doing the work the software will support, and focus on sustainable development.

Principles behind the Agile Manifesto;

1. Our highest priority is to satisfy the customer through early and continuous delivery of valuable software.

2. Welcome changing requirements, even late in development. Agile processes harness change for the customer's competitive advantage.

3. Deliver working software frequently, from a couple of weeks to a couple of months, with a preference to the shorter timescale.

4. Business people and developers must work together daily throughout the project.

5. Build projects around motivated individuals. Give them the environment and support they need, and trust them to get the job done.

6. The most efficient and effective method of conveying information to and within a development team is face-to-face conversation.

7. Working software is the primary measure of progress.

8. Agile processes promote sustainable development. The sponsors, developers, and users should be able to maintain a constant pace indefinitely.

9. Continuous attention to technical excellence and good design enhances agility.

10. Simplicity--the art of maximizing the amount of work not done--is essential.

11. The best architectures, requirements, and designs emerge from self-organizing teams.

12. At regular intervals, the team reflects on how to become more effective, then tunes and adjusts its behavior accordingly.” [4]

The Admissions application is completely built with Java Enterprise Edition 5 (Java EE 5) technologies. The UCDHS IT development team had worked for years to create its development environment using hands-on development experience in open-source technologies. The team researched, analyzed, compared, and concluded that the Java EE platform would be the UCDHS development environment.

Java EE provides seamless integration of persistence, controller/service, presentation layers, security (authentication and authorization) and a Java EE certified application server. The following Java EE 5 technologies are being utilized: JPA, EJB, JSF/ICEFaces, Security and Glassfish; each technology corresponds to a layer or a component mentioned above.

The software development tools used to create the SOM admissions application include;

▪ Java Persistence API (JPA) provides an object mapping facility that can correlate conceptualized object models in an enterprise environment and manage relational data in persistence layer.

▪ Enterprise Java Beans (EJB) provides services such as transactions, security, messaging and web services that encapsulates the business logic of an application.

▪ JavaServer Faces (JSF) is a server-side user interface component framework that provides the wiring of component-generated events to server-side application code.

▪ Java EE security services provide a robust security mechanism for authentication users and authorizing access to application functions and associated data.

▪ Glassfish is a Java EE certified application server that “ties” the above technologies together, so that developers can concentrate on building functions or features that satisfy business requirements.

▪ We use Netbeans as the primary development tool to build the application. Netbeans is a one-stop shop that provides fluid development experience to implementing enterprise applications.

▪ Database backend is using Oracle 11g.

Timeframe of Implementation

Software Application Development

Once the SHOULD process was completed, it was time to design and write the custom software application to support the SHOULD process. But a major decision had to be made on the timeframe of development.

Without new software to create and deployed the newly designed SHOULD process, another entire annual SOM admissions cycle would have to be done using the IS process and data collection methodologies with all of its flaws.

If there was any chance to create the new software in time for the next cycle of admissions (the 2009 class); work had to start immediately in June 2008. Furthermore, the software would have to be created in a just in-time approach; build the initial element of software needed to start the admissions cycle and deploy it, then build the rest of the software just as it was needed to carry out process tasks. The software would be built just as the work flowed through the process – left to right.

While fully understanding the risk of this approach, IT leadership offered to build the system during the 2009 admissions cycle, creating just in-time application modules, so SOM faculty and staff could use the new SHOULD process supported with new technology for the 2009 class. Work on the new software application started in June 2008 with only a partial SHOULD process map completed.

To meet this challenge, the IT development team used a variation of the agile software development methodology. The approach resulted in a step-wise software package deliverable every 30 days and allowed the SOM to keep pace with its previous timeline of processing applicants, understanding the school would not see any dramatic time line improvements until the entire SHOULD process was automated with the new software.

The first software module was delivered on July 15, 2008. The first module received the applicant data in electronic format from AMCAS, stored the data in a new admissions database, processed the applicants and immediately emailed them a notice that UC Davis School of Medicine had received their application and invited them to complete UC Davis’s online secondary application via the applicant’s designated web portal. As soon as the applicant completed the secondary application and paid the appropriate fee, a screener was assigned the file for further online review. The AMCAS application, the SOM secondary application, and all Letters of Recommendation were stored as PDF documents and made available online to the respective admissions personnel for easy viewing and review.

The second release in August 2008 supported online processing of secondary application fees and admissions screener assignments. It also allowed candidate screeners to view all applicant documents, make comments and finalize their recommendations online. At this point in previous years there would have been substantial delays in moving the process to the next step due to the amount of paper and photocopying involved as well as the delay incurred using inter-office mail to distribute and collect screener evaluations.

The third software release in October 2008 included functionality for applicants to sign up online and select their preferred interview day. The admissions administrative staff were given tools to create and publish interview dates, setup and collect interview evaluations online and monitor the overall process with real time ‘dashboards.’ The dashboards included functionality for admissions staff to be aware of any point in the process that was slowing down and provided software tools message and contact the appropriate person to keep the process moving forward. The dashboards also gave the staff real time statistics to ‘view’ the status of the entire admissions process; for example the number of applicants at any point in the process.

The fourth version released in November 2008 added selection committee functionality. As with previous releases the tools and links allowed the selection committees to view, comment on and make their recommendation all online. As with earlier modules, the applicant was immediately routed to the next phase of the admissions process removing all delays previously inherent from copying and moving paper files in the former IS process.

In January 2009 IT released the fifth version of software that included the tools to allow Program Directors, Admissions Directors and the Admissions Dean the ability to make final decisions. The full admissions process was completed using the SHOULD process and new custom software.

[pic]

[pic]

Customer Satisfaction

Opinion survey results from SOM applicants have dramatically improved when the results from the pre-electronic system is compared with the new system. With the new software, applicants are able to complete all requirements on-line, schedule their interview, keep track of their application, and all other activities associated to their application via the new applicant portal.

SOM faculty was also surveyed on the pre and post electronic admissions system, and the overwhelming majority of them liked the new system much better compared to the old paper format. The new software has helped improve recruitment of faculty for this important task of reviewing and interviewing applicants. The old paper-based process presented many challenges for busy faculty; they wasted significant time dealing with paper applicant files that had to be delivered to their offices. The new systems supports very streamlined interviews and records review and faculty can log onto the system from anywhere they have time to work on admissions.

Feedback from SOM faculty and staff has been very positive. Some of this feedback is shared below.

“Implementation of the electronic system has transformed our admissions process—making it faster and more user-friendly for applicants. The paperless system improves response time and reduces costs while providing applicants, faculty and administration with secure and real-time access. The system also creates a data-rich foundation which will help us maintain connections with our students well beyond graduation to build lifelong robust relationships.”

Claire Pomeroy, M.D., M.B.A.

Chief Executive Officer, UC Davis Health System, Vice Chancellor, Human Health Sciences, Dean, School of Medicine

“The prior process was characterized by lack of data and hence, poorly informed decisions, unacceptable delays associated with the paper process, and marked heterogeneity in the way applications were handled by individual screeners, interviewers, admissions office staff, and selection committees. The rapid deployment and technical support of the IT team has allowed us to take immeasurable steps forward in terms of security, efficiency, fairness, ease-of-use for faculty (e.g. web-based access from anywhere), and a more data-driven process including real-time surveys of all applicants that allow continuous quality improvement.”

Mark C. Henderson, MD, FACP, Associate Dean for Admissions, Residency Program Director, Department of Internal Medicine, UC Davis School of Medicine

“As the Director of Admissions for the School of Medicine for over 17 years, the opportunity to go "GREEN" is a blessing. Going "paperless" was long overdue. In all honesty, I cannot wait for the next admission cycle to begin in order to utilize the "new and improved" version. Overall, I have seen an increase in productivity by all those involved in this complicated process and see the benefits of the new system for future applicants and the success of the SOM to select, interview and admit the best applicants from a pool of thousands. I appreciated the team approach in the program's development and the responsiveness of the technology crew in making improvements as the system was underway.”

Edward D. Dagang, Director of Admissions & Outreach, UCD School of Medicine

“This single new use of technology in our education mission was the first step in a culture change that not only helped us be more responsive to prospective students but also emphasized to our health system our commitment to the environment”

Ann Bonham, Ph.D. was the UC Davis SOM Executive Associate Dean for Academic Affairs when this project started, and was a key supporter of the project.

Ann is now the Chief Scientific Officer of the Association of American Medical Colleges (AAMC)

“The new Health Science Student System or HS3 is going to help make us more efficient (operation, communication, management), improve service to current and prospective students, and provide necessary tools to track our students from admissions to graduation for evaluation purposes. The new admission system has transformed the entire admission process and dramatically improved our service to prospective students. Everything from assigning faculty roles to reviewing applicant file is done online with real-time tracking that help admissions staff enhance our management of over 5,000 files we process every year.”

Gurmeet "Roy" Rai, M.B.A., Manager, Office of Medical Education, UCD School of Medicine

“All in all I really liked the way the program stream-lined the process. …applications are available to the members so I didn’t have to worry about the mail, WHAT A RELIEF!!!!!!!”

Terri Hall, Office of Admissions Asst.

“There were no paper files to create and maintain.”

Lanina Sanders, Office of Admsisions Asst.

"Because the previous processes were by and large paper-based the impact IT had on the SOM process was minimal. The SOM did utilize a 10 year admissions software application that was developed in house, given the language the tool was written in we were not in a position to alter the program to keep pace with changing business needs. In addition, each year we had to copy the previous year’s database over for the incoming year. We were left with many databases that were not linked; they were not web-based and required IT staff to install the software on each person’s workstation. With the new software tool, it is all web based, there is no client software to install, the data is all integrated and substantially more secure. With the level of data we capture with the new application, we are able to provide very detailed metrics to the admissions staff to better aid them in the overall admissions process.”

Dan Cotton, Manager Educational Technology, UCDHS

One key cost saving opportunity was the 430,000+ sheets of paper that were photocopied and dispersed to the various admissions faculty and staff each admissions year. This breaks down to over 860 reams of paper. As it is estimated that a tree can make 17 reams of paper, if the SOM could become digital in its admissions process, 51 trees per year could be saved.

Digital processes save trees! [5]

Appendix – Software Examples

[pic]

UC Davis SOM Candidate portal



[pic]

Faculty Tool – Full online Screening of all Applications

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Online Dashboard for Faculty - Applicant Screening Detail

[pic]

Admissions Dean’s real-time Dashboard

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[1] From Rummler-Brache web site -

[2] 2012 AMCAS Instruction Manual,

[3] Agile web site:

[4] Agile web site:

[5] Image from ‘Reconsidering Recycled Paper Use’ Heike Soleinsky, Epoch Times, March 19, 2009

- Estimate of how many reams of paper a tree creates from -

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The new process and software is not just for students – all of the staff and faculty work to assess and interview students is also fully automated – and all content fully integrated

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