Continuous Quality Improvement Policy

Approved by College of Medicine Council- 9/12/2019

Policy

As part of the University of Cincinnati College of Medicine’s commitment to the highest standards of quality, this policy ensures systematic evaluation of the LCME Standards and Elements to promote efficiency, effectiveness and ongoing improvement of the medical education program.

The schedule for monitoring specific elements is based on the following criteria:

LCME Elements that have been cited as “not in compliance” or “compliance with monitoring” during previous reaccreditation visits.

New elements or elements in which LCME expectations have evolved (as communicated through meetings of the AAMC, the LCME website, or other communication from the secretariats).

Metrics that are included in the college's strategic plan and are the focus of current quality improvement efforts.

Elements that are affected by review or changes to UCCOM policies.

Elements for which outcomes related to the element are collected at regular, periodic intervals

or relate to regularly occurring processes (e.g., grade submissions, duty hours, mistreatment reports, and student well-being).

Evidence-Based Research: the EPC will review the literature on an ongoing basis to identify best practice strategies for CQI.

Results of institutional and national surveys (e.g. internal questionnaires, student feedback surveys, and AAMC Questionnaires) will be collected and reviewed on an ongoing, regular basis as part of the program evaluation process as well as items brought to the attention of the curriculum committees as areas of concern from the faculty or students.

The entire CQI cycle allows for a full mid-cycle review of all monitored elements.

Process for Monitoring

Since the majority of the elements for monitoring are curricular, the EPC and the Office of Medical Education (OME) monitor elements on an ongoing and “real-time” basis as part of the standing process of curricular management (i.e., developing and reviewing program objectives, determining curriculum gaps and redundancies, determining a balance of ambulatory inpatient clinical experiences, etc.), all of which is overseen by the EPC. The EPC is further charged to form working groups as needed to address any issues or concerns related to LCME Elements that have been cited as “not in compliance” or “compliance with monitoring” during the most recent reaccreditation visit. The ongoing work of the decanal offices is also aligned with the CQI process to ensure the other elements are appropriately monitored.

Reports are communicated by the EPC to the COM Council and dean bi-annually and more frequently as deemed necessary to address and review LCME elements that have been cited as “not in compliance” or “compliance with monitoring” during the most recent reaccreditation visit. The EPC and the senior associate dean for educational affairs work with UCCOM constituents to address compliance issues that arise as part of this ongoing monitoring process. Reports are readily available online for review by all faculty and students on MedOneStop, a comprehensive student information system, under the “Other Resources” tab, under the curriculum committee agenda minutes.

Administrative Support

Associate Dean for Medical Education

• Oversee all CQI activities including, but not limited to:
• Collecting and reviewing data
• Monitoring action items
• Developing and maintaining a CQI dashboard
• Developing and disseminating reports

• Collaborate with members of the CQI Steering Committee and relevant student leadership as part of the process of compiling and presenting an annual summary
• Collaborate with and support the senior associate dean for educational affairs to facilitate a full-review mid-cycle
• Serve as the institutional faculty liaison to the LCME
• Communicate LCME-related updates to all relevant leaders and stakeholders
• Maintain updated accreditation information
• Participate in LCME webinars
• Conduct an annual review of the “Functions and Structure of a Medical School” as well as the Data Collection Instrument to ensure data collection is up-to-date
• Attend LCME-sponsored sessions at national and regional conferences

Assistant Dean for Medical Education

Since all LCME elements require regular monitoring, the assistant dean: 1) develops curricular dashboards, 2) identifies trends in student performance, 3) recommends areas of focus, and 4) recommends strategies to facilitate improvements in the evaluation of outcomes related to program objectives.

Director of Medical Education

This senior medical education staff person assists in: 1) maintaining the CQI compliance monitoring dashboard, 2) drafting annual summary reports, and 3) supporting the full mid-cycle review process. The director also participates in LCME webinars, supports the annual review using the LCME Standards and Elements as well as the DCI templates, and attends LCME-sponsored workshops and sessions at national and regional meetings.

Related LCME Standard

Element 1.1: Strategic Planning and Continuous Quality Improvement. ”A medical school engages in ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goals, result in the achievement of measurable outcomes used to improve programmatic quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards.”