The study aimed to describe the procedures implemented by medical colleges in Pakistan to assure quality in their assessment system. Method: A qualitative study was conducted from March 2015-December 2017 in medical colleges of Pakistan using grounded theory design. The medical colleges were selected by using non-probability convenient sampling technique. Out of the total 93 PMDC (Pakistan Medical and Dental Council) recognized medical colleges, 49 were selected from all four provinces of

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... an as well as Azad Kashmir. An open-ended questionnaire was filled by one faculty member from each participating medical college after obtaining informed consent. Data was analyzed using SPSS version 21 (IBM). Results: Majority participants appreciated their institution's assessment policy and wished improvement in terms of comparability to national organization's assessment systems. For about 1/3rd of participants developing standardized tools, their grading (e.g. SEQs), and faculty's unwillingness to devote time for quality MCQ were the challenges. Recommendations by > 1/3rd to overcome barriers included one assessment per year, improvement in teaching methods, standardized assessment, and structured viva exams. In >1/2 institutions no audit of assessment process was conducted. Around 1/3rd confirmed audit was an irregular unplanned activity and no report published. Around 1/4th of participants highlighted that a formal audit report stemmed in improving teaching & examination methods. Conclusions: Overall Quality Assurance (QA) procedures in assessment system in Pakistan were poorly implemented. Lack of QA and Monitoring & Evaluation (M&E), feedback mechanism, benchmarks for assessors, and formal auditing was noted. Student's involvement, & semester system was recommended.