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: 6/21/21

Next Review: 6/21/24

Contact: Michael Whitt, PhD

Associate Dean, Medical Education

🕿 901-448-4634


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.


  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 LCME Quality Improvement & Compliance Committee (LCME QICC). The LCME 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 supports reporting and helps to ensure timeliness of the monitoring process. These personnel have assigned responsibilities and dedicated effort for this process.
  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.
  4. 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.
  5. 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:
  2. 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.
  3. 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:
  4. Elements with an explicit requirement for monitoring, including those involving a regularly-occurring process.
  5. New elements, recently-revised elements, and elements where LCME expectations have evolved.
  6. Elements that document congruency of policies and operations.
  7. Elements affecting core operations of the school, either directly or indirectly.
  8. Elements (standards) cited in the previous full survey.
  9. Elements identified as an area of concern by the QICC.
  10. CQI initiatives related to strategic planning or emerging needs:
  11. 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.
  12. 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.
  13. 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).
  14. 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).
  15. For each CQI review cycle, documentation should include:
  16. 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.
  17. 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).
  18. 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. Table 1. LCME Elements to be Monitored


  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
  5. 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: 6/21/21

Table 1: LCME Elements to Be Monitored

Element 1.4

Affiliation Agreements

Element 1.5


Element 3.3

Diversity/Pipeline Programs and Partnerships

Element 3.5

Learning Environment/Professionalism

Element 4.1

Sufficiency of Faculty

Element 4.4

Feedback to Faculty

Element 4.5

Faculty Professional Development

Element 5.1

Adequacy of Financial Resources

Element 7.1

Biomedical, Behavioral, Social Sciences

Element 7.9

Interprofessional Collaborative Skills

Element 8.1

Curricular Management

Element 8.2

Use of Medical Educational Program Objectives

Element 8.3

Curricular Design, Review, Revision/Content Monitoring

Element 8.4

Program Evaluation

Element 8.5

Medical Student Feedback

Element 8.6

Monitoring of Completion of Required Clinical Experiences

Element 8.8

Monitoring Student Time

Element 9.1

Preparation of Resident and Non-Faculty Instructors

Element 9.4

Assessment System

Element 9.5

Narrative Assessment

Element 9.7

Formative Assessment and Feedback

Element 9.8

Fair and Timely Summative Assessment

Element 9.9

Student Advancement and Appeal Process

Element 11.2

Career Advising

Element 12.1

Financial Aid/Debt Management Counseling/Student Educational Debt

Element 12.4

Student Access to Health Care Services

Element 12.5

Non-Involvement of Providers of Student Health Services in Student

Assessment/ Location of Student Health Records

Element 12.8

Student Exposure Policies/Procedures

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