Educational Continuous Quality Improvement (ECQI) Policy

PURPOSE
To outline the UC Davis School of Medicine’s policy and procedure for monitoring accreditation elements. The School of Medicine is committed to engaging in a continuous and intentional process aimed at supporting improvements in the medical education program. Continuous monitoring of Liaison Committee on Medical Education (LCME) accreditation elements ensures accreditation-readiness and the incorporation and awareness of national trends and emerging issues

AUDIENCE
UC Davis faculty, staff, and students

LCME STANDARD
1.1: Strategic Planning and Continuous Quality Improvement

POLICY

  1. The UC Davis School of Medicine shall maintain continuous quality improvement to regularly monitor the quality of the medical education program, and assure all standards mandated by the Liaison Committee for Medical Education (LCME) are being met.
  2. The Educational Continuous Quality Improvement (ECQI) and Accreditation Officer and the Associate Dean for Workforce Innovation and Education Quality Improvement, with the ECQI Working Group, will determine which elements are monitored, the timing of element monitoring, the individuals/groups receiving the results of the monitoring, the individuals/groups responsible for taking action, and monitoring the outcomes of the actions.
  3. The ECQI Working Group is convened by the ECQI and Accreditation Officer and Associate Dean for Workforce Innovation and Education Quality Improvement at least quarterly. 
  4. Membership includes faculty and staff members from the committees involved in receiving and acting on results from the review of institutional data and LCME elements. Representatives include:
    1. Associate Dean for Workforce Innovation and Education Quality Improvement (co-chair)
    2. ECQI & Accreditation Officer (co-chair)
    3. Vice Dean for Medical Education
    4. Associate Dean for Curriculum and Medical Education
    5. Associate Dean for Students
    6. Associate Dean for Admissions
    7. Assistant Dean for Medical Education
    8. Assistant Dean for Student Learning and Academic Enrichment
    9. Assistant Dean for Admissions, Outreach, Recruitment, and Retention
    10. Chair of the Faculty Executive Committee
    11. Chair of the Committee on Educational Policy
    12. Chair of the Committee on Student Promotions
    13. Director of Curriculum and Educational Technology
    14. Associate Dean for Student and Resident Diversity
    15. Associate Dean for Graduate Medical Education
    16. Associate Dean for Assessment, Evaluation, and Scholarship
    17. Associate Dean for Rural and Community-based Education
    18. Director of Student Affairs
    19. Medical Student Representatives (4)

PROCEDURE

  1. All LCME standards are reviewed, at a minimum, annually
  2. Areas that need improvements are monitored with data collection using a Plan-Do-Study-Act cycle quality improvement process
  3. Areas of monitoring include, but are not limited to:
    1. Elements that include an explicit requirement for monitoring or involve a regularly occurring process
    2. New or recently revised or changes in LCME expectations related to performance in elements
    3. Elements that could be reviewed to ensure that policies are congruent with current operations
    4. Elements that directly or indirectly affect the core operations of the school
    5. Elements that were cited in the medical school’s previous accreditation surveys
    6. Elements that were commonly cited in the last three years
    7. Other elements that were identified through program evaluation processes, the Curriculum Committee, or School of Medicine leadership
    8. LCME elements impacting student well-being and ongoing operations (student mistreatment, duty hour violations, clerkship mid-point feedback, grade timeliness, course review) undergo an ongoing operational review
    9. Elements with falling internal or external program evaluation metrics, including the Graduation Questionnaire and Mission Management Tool
    10. Elements related to strategies and tactics of the School of Medicine strategic plan
  4. The ECQI Workgroup will identify the following components to successful monitoring for each element in the above categories:
    1. Key process and outcome metrics related to the element, from specified data sources
    2. Defining internal target(s) for compliance with the element
    3. Determining optimal review cycle
    4. Determining the appropriate individuals and committee for periodic review and schedule for committee discussion
    5. Determining whether outcome metrics were achieved
  5. Documenting the individuals or committee to receive the results of a review 
  6. Documenting the individuals or groups responsible for taking action on the results of the review
  7. Logging and monitoring action items from committees and reviewing elements to ensure follow-up on action items
  8. Maintain up-to-date knowledge on accreditation elements and distribute education and updates to stakeholders

RESPONSIBILITY
ECQI Working Group

REFERENCES
LCME

POLICY OWNER
Office of Medical Education

REVIEWED BY
ECQI Working Group

REVIEWED DATE and REVIEW CYCLE
July 2024; annual review cycle