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: 6/21/21
Next Review: 6/21/24
Contact: Michael Whitt, PhD
Associate Dean, Medical Education
Related Policy: N/A
Attachments: Table 1: LCME Elements to Be Monitored
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.
GOALS & RATIONALE
- 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.
- 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.
RESPONSIBLE UNITS & PERSONNEL
- Primary responsibility for and authority to manage the effort of monitoring lies with the LCME Quality Improvement & Compliance Committee (LCME QICC). The LCME QICC is chaired by the Associate Dean for Medical Education.
- 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 supports reporting and helps to ensure timeliness of the monitoring process. These personnel have assigned responsibilities and dedicated effort for this process.
- 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.
- Results of monitoring are communicated to CUME and to relevant academic unit(s). LCME QICC has primary responsibility to assure that the CQI process is on track and to provide timely updates to the CUME.
- 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.
- Monitoring of LCME standards and elements:
- Monitoring is scheduled on a continuous basis in accordance with this policy. For each monitored element, supporting data and narratives specified by the Data Collection Instrument (DCI) form the basis of review. Adequacy of resources to conduct monitoring is coordinated by OME.
- Elements subject to monitoring are specified in the attachment (Table 1. LCME Elements to be Monitored). Additional elements may be added as deemed appropropriate by the QICC. Categories of elements to be monitored include but are not limited to:
- Elements with an explicit requirement for monitoring, including those involving a regularly-occurring process.
- New elements, recently-revised elements, and elements where LCME expectations have evolved.
- Elements that document congruency of policies and operations.
- Elements affecting core operations of the school, either directly or indirectly.
- Elements (standards) cited in the previous full survey.
- Elements identified as an area of concern by the QICC.
- CQI initiatives related to strategic planning or emerging needs:
- 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.
- The process outlined below 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.
- Other CQI projects may be identified based on information from course or clerkship reviews, or from student surveys including Graduation Questionnaires (GQs), Year 2 Questionnaires (Y2Qs), or COM-specific surveys. The process outlined below will support CQI projects identified from these sources and deemed as areas in need of improvement by the QICC or the curriculum committees (CMDCS, CSS or CUME).
- 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:
- A completed copy of the CQI template, which includes a determination of compliance and action items that are needed for the next steps in the iterative cycle.
- A draft copy of the relevant DCI Element(s) when monitoring DCI Standards and Elements. The review should include an internal assessment of status (satisfactory, satisfactory with a need for monitoring, or unsatisfactory).
- 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.
- Table 1. LCME Elements to be Monitored
- LCME White Paper “Implementing a System for Monitoring Performance in LCME Accreditation Standards” Oct. 2016 (available at http://lcme.org/publications/#All)
- LCME Data Collection Instrument for Full Accreditation Surveys (available at http://lcme.org/publications/#All )
- 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
- 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
- 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
Table 1: LCME Elements to Be Monitored
Diversity/Pipeline Programs and Partnerships
Sufficiency of Faculty
Feedback to Faculty
Faculty Professional Development
Adequacy of Financial Resources
Biomedical, Behavioral, Social Sciences
Interprofessional Collaborative Skills
Use of Medical Educational Program Objectives
Curricular Design, Review, Revision/Content Monitoring
Medical Student Feedback
Monitoring of Completion of Required Clinical Experiences
Monitoring Student Time
Preparation of Resident and Non-Faculty Instructors
Formative Assessment and Feedback
Fair and Timely Summative Assessment
Student Advancement and Appeal Process
Financial Aid/Debt Management Counseling/Student Educational Debt
Student Access to Health Care Services
Non-Involvement of Providers of Student Health Services in Student
Assessment/ Location of Student Health Records
Student Exposure Policies/Procedures