Continuous Quality Improvement

The College of Human Medicine will engage in ongoing monitoring of our program’s compliance with the Liaison Committee on Medical Education (LCME) accreditation standards using a continuous quality improvement (CQI) approach.

CQI Structure and Resources

The CQI Office is part of Academic Affairs, Dean’s Office. The Senior Associate Dean for Academic Affairs (SADAA) is responsible for LCME accreditation as the College’s Chief Academic Officer. The Assistant Dean for Program Evaluation and Continuous Quality Improvement and the Executive Administrative Assistant perform much of the CQI process in partnership with the SADAA and the CQI Committee.

The CQI Committee is comprised of the SADAA, Executive Director for Academic Affairs, Senior Associate Dean of Diversity, Associate Dean for Undergraduate Medical Education, Assistant Dean for Student Affairs, Assistant Dean for Admissions, and Assistant Dean for Program Evaluation and Continuous Quality Improvement.

Academic Affairs maintains a specific budget for LCME accreditation and the CQI process. The budget is managed by the SADAA and the Executive Director for Academic Affairs. The college Business Office and dean prioritize additional funding requests pertaining to meeting the LCME requirements.

Monitoring Plan

The subsections included in the narrative below are as stated in the LCME Data Collection Instrument, Full, 2022-2023, under Element 1.1.

• Which elements are monitored (e.g., all standards, a subset of standards)?

  The college plans to monitor all elements each year. In addition, we have prioritized our most intensive monitoring efforts according to the following principles:

  • Elements cited in previous LCME surveys
  • Elements identified during the monitoring process as requiring active management to ensure compliance
  • New/recently revised elements
  • Elements with specific monitoring requirements
  • Elements core to the mission of the college and university
• How often is compliance with elements reviewed (mid-cycle, yearly, at some other interval)?

  The CQI Committee meets quarterly. Priority elements are reviewed each quarter. All other elements are reviewed at least annually. At the quarterly meeting, we update a CQI monitoring report which classifies each element as no concern, needs monitoring, needs attention. The report also notes date of review, data source, responsible individuals/groups, and notes for follow-up activities and future monitoring discussions. Elements classified as needs monitoring and needs attention are reviewed at subsequent CQI meetings until such time as the classification changes to no concern.

• What data sources are used to monitor compliance?

  The CQI monitoring plan uses many different data sources, including but not limited to the following:

  • AAMC Surveys including matriculating student questionnaire (MSQ), year-two questionnaire (Y2Q), the graduate questionnaire (GQ), and the annual medical school financial questionnaire.
  • College created and managed student experience survey.
  • College created and managed graduate follow-up survey.
  • Independent Student Survey
  • Student assessment data including performance on the necessary science exams, progress clinical skills exams, and clerkship exams.
  • Clinical Education Agreements – list and templates
  • Student evaluations of rotations, clerkships, sites, and preceptors
  • College and university committee reports and minutes.
  • College and university policies, procedures, bylaws, organizational charts, and other organizational documents.
  • College created reports for managing the work of the college including admissions, financial aid, and residency match results.
• What individuals or groups receive the results?

  The college has a multi-pronged approach based on three key principles:

  • College leadership, faculty, staff, and students need information to be part of the efforts to continuously assess and improve the medical school.
  • Providing information requires more than making a report publicly available. To be true partners, we need to engage leadership, faculty, staff, and students in the process so they can meaningfully contribute to continuous quality improvement efforts.
  • Recognizing the limitations of people’s time and attention requires that we draw attention to the elements most relevant to the work they do.

  The CQI monitoring report was created as a dashboard to highlight priority areas for our teams to address. It is shared in multiple venues as a way to engage the entire college in efforts to continuously monitor and improve the quality of the educational program and the health of the medical school. Each of these opportunities connects college team members with relevant portions of the CQI monitoring process and provides an opportunity for discussion, problem-solving and strategizing. Primary distribution pathways are the following:

  • The CQI monitoring report is shared with the dean after each quarterly meeting.
  • The CQI monitoring report is shared with the Academic Affairs leadership after each quarterly meeting.

  In addition, faculty, staff, and student governance are engaged in these efforts through the following avenues.

  • CHM Curriculum Committee receives the annual report from Associate Dean for Undergraduate Medical Education, lead clerkship directors, and clinical experiences directors.
  • The Senior Associate Deans for Academics, Faculty Affairs and Staff Administration, Diversity, and Research meet with the dean weekly to discuss topics of importance to the college, our students, faculty, and staff. SADAA orally presents any elements requiring active engagement with other units in the Dean’s Office to ensure a coordinated effort by the dean’s office.
  • Elements requiring broad involvement across the college are presented at the monthly college leadership meetings which include leadership from the dean’s office, departments, divisions, and community campuses.
  • Elements requiring collaboration between department chairs are discussed at the monthly Chairs/Directors meetings which include topics covering research, education, and clinical care.
  • The SADAA also provides regular updates to the College Advisory Council which includes college leadership, faculty and students and engages them in strategizing priorities and how best to address areas for improvement.
  • The SADAA also provides regular updates to the Deans Student Advisory Committee which includes student representatives from all campuses and levels and engages them in strategizing priorities and how best to address areas for improvement.
  • The SADAA also provides regular updates to the Deans Staff Advisory Committee which includes staff representatives from departments and units across the college and engages them in strategizing priorities and how best to address areas for improvement.