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
The UC Davis School of Medicine shall maintain continuous quality improvement (CQI) 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. The Director of Educational Assessment, Scholarship, Improvement and Innovation (EASII) and the Educational Continuous Quality Improvement (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.

The ECQI Working Group is convened by the EASII Director and Associate Dean for Workforce Innovation and Education Quality Improvement at least quarterly.  Membership includes key staff and faculty stakeholders from the committees involved in receiving and acting on results from review of institutional data and LCME elements, with representatives including:

  1. Associate Dean for Workforce Innovation and Education Quality Improvement (co-chair)
  2. Director of Educational Assessment, Scholarship, Improvement and Innovation (co-chair)
  3. Vice Dean of Medical Education
  4. Associate Dean for Curriculum
  5. Associate Dean for Students
  6. Assistant Dean of Medical Education
  7. Chair of the Faculty Executive Committee
  8. Chair of the Committee on Educational Policy
  9. Chair of the Admissions Committee
  10. Chair of the Committee on Student Promotions
  11. Medical Student Representatives (2)
  12. Director of Curriculum and Educational Technology
  13. Director of Outreach, Recruitment, and Retention
  14. Associate Dean of Diverse and Inclusive Education (curriculum focused)

PROCEDURE
The EASII Director and the ECQI Working Group will use the following procedures to assure compliance with accreditation elements:

    1. All LCME standards will be reviewed, at a minimum, annually, and any areas that need improvements will be monitored with data collection using a Plan-Do-Study-Act (PDSA) cycle quality improvement process. 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 effect 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 via School of Medicine leadership
      8. LCME elements impacting student well-being and ongoing operations (student mistreatment, duty hour violations, mid-clerkship feedback, grade timeliness, course review) undergo an ongoing operational review
      9. Elements with falling internal or external program evaluation metrics, including the Graduation Questionnaire (GQ) and Mission Management Tool (MMT)
      10. Elements related to strategies and tactics of the School of Medicine strategic plan
    2. 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
    3. Documenting the individuals or committee to receive the results of review 
    4. Documenting the individuals or groups responsible for taking action on the results of the review
    5. Logging and monitoring action items from committees and reviewing elements to ensure follow-up on action items
    6. Maintain up-to-date knowledge on accreditation elements and distribute education and updates to relevant stakeholders

RESPONSIBILITY
Educational Assessment, Scholarship, Improvement and Innovation Unit

REFERENCES
LCME

POLICY OWNER
Educational Assessment, Scholarship, Improvement and Innovation Unit

REVIEWED BY
Educational Continuous Quality Improvement Workgroup

REVIEWED DATE and REVIEW CYCLE
July 2022; annual