Abstract Background: The methods used for assessment of students in osteopathic teaching institutions are not widely documented in the literature. A number of commentaries around clinical competency assessment have drawn on the health professional assessment literature, particularly in medicine. Objective: To ascertain how osteopathic teaching institutions assess their students and to identify issues associated with the assessment process. Design: A series of focus groups and interviews was undertaken with osteopathic teaching institutions. Participants: Twenty-five participants across eleven osteopathic teaching institutions from the United Kingdom, Canada, Italy and Australia. Results: Four themes were identified from the focus groups: Assessing; Processes; Examining; Cost Efficiency. Institutions utilised assessment types such as multiple choice questions and written papers in the early years of a program and progressed towards the long case assessment and Objective Structured Clinical Examination in the later stages of a program. Although examiner cost and training were common themes across all of the institutions, they were perceived to be necessary for developing and conducting assessments.