COM101 Continuous Quality Improvement – COM Medical Education

No./Title: COM101/CQI Policy

Resp. Office: Office of Medical Education (OME)

Approval Body: Committee on Undergraduate

Medical Education (CUME)

Effective Date: 4/16/18

Category: COM UME

Last Review: 6/20/22

Next Review: 6/20/25

Contact: Michael Whitt, PhD

Associate Dean, Medical Education

 901-448-4634

Related Policy: N/A



It is the policy of the University of Tennessee Health Science Center (UTHSC) College of Medicine (COM) to engage in a process of continuous quality improvement (CQI) to ensure alignment of activities with the COM’s values, mission, and strategic plan, and to provide effective monitoring of compliance with accreditation standards as outlined herein.


  1. This policy describes goals, procedures, and documentation related to monitoring of continuous improvement efforts within the COM. Relevant initiatives may relate to ensuring compliance with accreditation standards, meeting strategic planning goals of the COM as presented in the COM Strategic Plan, or may be in response to newly identified needs or challenges.
  2. This policy is intended to align with expectations of the Liaison Committee on Medical Education (LCME) with regard to internal monitoring of accreditation elements in the intervals between scheduled site visits. Furthermore, it is intended to provide central oversight of broad-based initiatives to achieve the missions of the COM, including student success, a strong statewide clinical enterprise, a robust research portfolio, and meaningful community partnerships.


  1. Primary responsibility for and authority to manage the effort of monitoring lies with the COM Quality Improvement & Compliance Committee (QICC). The QICC is chaired by the Associate Dean for Medical Education.
  2. Support of monitoring procedures and management of documentation is coordinated by the Evaluation and Assessment Team and is conducted within the Office of Medical Education (OME). The Evaluation and Assessment Team is responsible for collating results from established outcome measures, generating dashboards that show performance in relation to expectations, and providing access to reports. As such, the Evaluation and Assessment Team helps to ensure timeliness of the monitoring process. These personnel have assigned responsibilities and dedicated effort for these activities.
  3. Additional support, as needed, is provided by COM curriculum committees, by the office of the

Robert Kaplan Executive Dean, and by UTHSC’s Office of Institutional Effectiveness.

  1. Results of monitoring are communicated to CUME and to relevant academic unit(s). The QICC has primary responsibility to assure that the CQI process is on track and to provide timely updates to the CUME.
  2. While QICC has direct responsibility for CQI activities within the purview of the medical education program, including student support services, its role may vary with initiatives based in other administrative units (e.g. clinical practice groups, UTHSC Office of Research). As appropriate for projects in other administrative units, the Robert Kaplan Executive Dean or his appointee has primary responsibility for oversight.


  1. Monitoring of LCME standards and elements:
    1. Individual members of the QICC are assigned one of the 12 LCME Standards. These individuals are responsible for reviewing the data when outcome data become available (e.g. the GQ in late July, the Y2Q in March/April and various internal surveys including end-of-course ). The Senior Evaluation and Assessment Analyst, who puts survey results into the Evaluation and Assessment dashboard, will notify all members of the QICC when new survey results are available. Elements containing areas in which student satisfaction and/or performance falls below the national average, those that show a downward trend, or that do not meet the COM’s internal benchmarks will be reviewed at the next QICC meeting and action plans developed to address the root causes for the drop in performance. For each monitored element, supporting data and narratives specified by the Data Collection Instrument (DCI) form the basis of review.
    2. Elements subject to monitoring are listed on the LCME Dashboard housed on the QICCSharepoint site (requires login). Additional elements are added as deemed appropropriate by the QICC. Categories of elements to be monitored include but are not limited to:
      1. Elements with an explicit requirement for monitoring, including those involving a regularly- occurring process.
      2. New elements, recently-revised elements, and elements where LCME expectations have evolved.
      3. Elements that document congruency of policies and operations.
      4. Elements affecting core operations of the school, either directly or indirectly.
      5. Elements (standards) cited in the previous full survey.
      6. Elements identified as an area of concern by the QICC.
  2. CQI initiatives related to strategic planning or emerging needs:
    1. On an ad hoc basis, this policy is used to support effective and well-documented implementation of diverse initiatives linked to the mission of the COM and its Strategic Plan.
    2. The process may support CQI projects stemming from the COM’s Strategic Plan, from campus accreditation by the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC), or from other emerging needs as identified by COM leadership.
  3. The CQI process is based on the Deming cycle for continuous quality improvement and consisting of a 4-step iterative process (PDSA; Plan, Do, Study, Act). For each CQI review cycle, documentation should include:
    1. A completed copy of the CQI PDSA template, which includes the overall objective, the individual(s) responsible, the data sources used and outcome measures to be tracked, a determination of compliance and action items with a timeline for completion needed for the next steps in the iterative cycle.
    2. A description of the relevant element when monitoring DCI Standards and Elements, the component of the Strategic Plan, or information from other accreditating bodies (e.g. SACSCOC). The review should include an internal assessment of the status; for example, compliant or satisfactory, compliant but in need of monitoring (e.g. improvements needed), or non- compliant/unsatisfactory (high priority action needed).
  4. The QICC has primary responsibility for tracking the progress and status of CQI activities with particular attention to adherence with LCME expectations. The Evaluation and Assessment Team has responsibility for coordinating documentation. Reporting of CQI activities to CUME occurs monthly and is a recurring item on the CUME agenda.


  1. LCME White Paper “Implementing a System for Monitoring Performance in LCME Accreditation Standards” Oct. 2016 (available at
  2. LCME Data Collection Instrument for Full Accreditation Surveys (available at
  3. Barzansky B, Hunt D, Moineau G, Ahn D, Lai C-W, Humphrey H, Peterson L, 2015. “Continuous quality improvement in an accreditation system for undergraduate medical education: benefits and challenges.” Med Teacher 37:11, 1032-1038
  4. Hunt D, Migdal M, Waechter DM, Barzansky B, Sabalis RF, 2016. “The variables that lead to severe action

decisions by the LCME.” Acad Med 91:1, 87-93

  1. Taylor MJ, McNicholas C, Nicolay C, Darzi A, BelD, Reed JE, 2014. Systematic review of the application of the PDSA method to improve quality in healthcare. BMJ Qual Saf 23, 290-298


Effective: 4/16/18 Revised: 6/20/22

COM101 Continuous Quality Improvement – COM Medical Education
Version: 1 // Effective: 04/16/2018
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