Educational Continuous Quality Improvement (ECQI) Policy

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

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 ensure all LCME standards and expectations are being met.
  2. The Educational Continuous Quality Improvement (ECQI) and Accreditation Officer and the Associate Dean for Workforce Innovation and Education Quality Improvement (EdCQI), with the ECQI Work Group, are responsible for monitoring all accreditation standards and elements on a regular interval; identifying and synthesizing data relevant to the standards; presenting the data to leadership, unit and/or governance committees, staff, and students; and recommending to the accountable leader actions to address deficiencies and implement improvement strategies.
  3.  The ECQI Work Group establishes measurable outcomes to track the effectiveness of interventions and support continuous improvement.
  4. The Associate Dean for Workforce Innovation and EdCQI, and the ECQI and Accreditation Officer, in collaboration with the Office of Medical Education, appoint a  Work Group on ECQI to provide direction to the School's ECQI initiatives and accreditation standards.
    • The ECQI Work Group is co-chaired by the Associate Dean for Workforce Innovation and EdCQI and the ECQI and Accreditation Officer.  
  5. The ECQI Work Group convenes quarterly and is a collaboration between faculty, staff, and student members from the committees involved in receiving and acting on results from the review of institutional data and LCME elements.

PROCEDURE

  1. The frequency of review of standards is as follows:
    1. Annual reviews of all standards.
    2. Bi-annual or more frequent reviews may be appropriate for the following standards:
      1. Elements impacting student well-being, learning environment, assesment, and trajectory through the curriculum.
      2. New and.or revised LCME standards.
      3. Standards for which the School was found to be out of compliance at the most recent LCME accreditation review.
      4. Any standards for which the LCME mandates review of this frequency.
    3. At any time, the responsible associate dean(s), assistant dean(s), or director(s) may request that data be brought to the attention of the relevant governance committee.
  2. The ECQI Work Group 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. The ECQI Work Group maintains an up-to-date knowledge on accreditation elements and distributes education and updates to stakeholders
    1. This includes an element monitoring database which incorporates, for each element, the frequency of review, the individuals or groups receiving the results, the accountable deal, associated action item(s), and internal compliance determinations.
    2. This process is reviewed annually.

RESPONSIBILITY
ECQI Work Group

REFERENCES
LCME

POLICY OWNER
Office of Medical Education

REVIEWED BY
ECQI Work Group

REVIEWED DATE and REVIEW CYCLE
July 2026; annual review cycle