The REASON Framework for quality-assured MCQ assessment in health-professional and bioscience education: six practical steps from question design to post-assessment analysis

Multiple-choice question (MCQ) assessment is widely used across health-professional and bioscience education because it enables broad curriculum sampling, efficient administration, objective scoring and post-assessment review of item performance. However, MCQ assessment quality is not guaranteed by the format alone. It depends on how items are designed, reviewed, administered, analysed and used within the wider assessment system. This narrative review synthesises practical principles for quality-assured and inclusive MCQ assessment in health-professional and bioscience education. It considers how question design, pre-assessment review and post-assessment analysis can support assessment decisions that are valid, reliable, fair and well-evidenced. The review synthesises literature relating to item writing, distractor quality, blueprinting, peer review, faculty development in the form of item-writer training, accessibility, feedback, post-test item analysis, reliability, validity and standard setting, and organises it around three assessment-lifecycle pillars: question design, pre-assessment review and post-assessment analysis. Equity, standards and governance are considered as quality considerations that apply across question design, pre-assessment review and post-assessment analysis. The review culminates in the REASON Framework: Results-aligned blueprinting, Evidence-informed item design, Accessible and inclusive assessment design, Structured pre-assessment review, Outcomes-informed post-assessment analysis, and Nurturing assessment literacy and quality cycles. This framework presents a practical organising mnemonic for educators, programme teams and assessment leads seeking to strengthen MCQ assessment quality across diverse health-professional and bioscience curricula.