LCME Subcommittee 1

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 that are used to improve programmatic quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards.

Evaluate the utility and success of institutional planning efforts, and summarize how planning has contributed to the accomplishment of the medical school’s missions and the achievement of measurable outcomes.  How effective is the medical school’s system for monitoring its ongoing compliance with accreditation standards? (1.1)

1.2
Conflict Of Interest Policies

A medical school has in place and follows effective policies and procedures applicable to board members, faculty members, and any other individuals who participate in decision-making affecting the medical education program to avoid the impact of conflicts of interest in the operation of the medical education program, its associated clinical facilities, and any related enterprises.

Evaluate the adequacy of the structures, policies, and other safeguards in place to prevent or identify conflicts of interest at the level of the governing board, the medical school administration and faculty, and others with responsibility for the medical education program. Note the extent that they are being followed. (1.2)

1.3
Mechanisms For Faculty Participation

A medical school ensures that there are effective mechanisms in place for direct faculty participation in decision-making related to the medical education program, including opportunities for faculty participation in discussions about, and the establishment of, policies and procedures for the program, as appropriate.

Evaluate the effectiveness of mechanisms for direct faculty involvement in decision-making related to the medical education program, including participation in relevant committees.  Are there sufficient opportunities outside of formal committees for faculty to learn about and comment on medical school policies and procedures?  Do members of the faculty consider that they have sufficient opportunities to make themselves heard? (1.3)

1.4
Affiliation Agreements

In the relationship between a medical school and its clinical affiliates, the educational program for all medical students remains under the control of the medical school’s faculty, as specified in written affiliation agreements that define the responsibilities of each party related to the medical education program. Written agreements are necessary with clinical affiliates that are used regularly for required clinical experiences; such agreements may also be warranted with other clinical facilities that have a significant role in the clinical education program. Such agreements provide for, at a minimum the following:

• The assurance of medical student and faculty access to appropriate resources for medical student education
• The primacy of the medical education program’s authority over academic affairs and the education/assessment of medical students
• The role of the medical school in the appointment and assignment of faculty members with responsibility for medical student teaching
• Specification of the responsibility for treatment and follow-up when a medical student is exposed to an infectious or environmental hazard or other occupational injury
• The shared responsibility of the clinical affiliate and the medical school for creating and maintaining an appropriate learning environment

Does the medical school have up-to-date affiliation agreements with the clinical partners that are used regularly for required inpatient clinical experiences?  Evaluate whether agreements contain the language specified in the element and serve to ensure that the educational program for medical students remains under the control of the medical school’s faculty. (1.4)

A medical school promulgates bylaws or similar policy documents that describe the responsibilities and privileges of its administrative officers, faculty, medical students, and committees.

1.6
Eligibility Requirements

A medical school ensures that its medical education program meets all eligibility requirements of the LCME for initial and continuing accreditation, including receipt of degree-granting authority and accreditation by a regional accrediting body by either the medical school or its parent institution.

Evaluate whether the medical school has met and maintained the eligibility requirements for initial and continuing LCME accreditation, as specified in the Rules of Procedure. (1.6)

2.1
Administrative Officer And Faculty Appointments

The senior administrative staff and faculty of a medical school are appointed by, or on the authority of, the governing board of the institution.

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How is the authority of the governing board for the appointment of medical school administrators and faculty being exercised?  Has appropriate authority for appointments been delegated by the board to the university and medical school administration? (2.1)

2.2
Dean’s Qualifications

The dean of a medical school is qualified by education, training, and experience to provide effective leadership in medical education, scholarly activity, patient care, and other missions of the medical school.

Comment on the qualifications of the dean to provide leadership in all the missions of the medical school.  Is there a clear definition of and general understanding of the dean’s authority and responsibility for the medical school and its educational program?  Evaluate whether the dean has appropriate access to university and other officials, so as to support his or her ability to carry out these defined responsibilities. (2.2, 2.3)

2.3
Access And Authority Of The Dean

The dean of a medical school has sufficient access to the university president or other institutional official charged with final responsibility for the medical education program and to other institutional officials in order to fulfill his or her responsibilities; there is a clear definition of the dean’s authority and responsibility for the medical education program.

Comment on the qualifications of the dean to provide leadership in all the missions of the medical school.  Is there a clear definition of and general understanding of the dean’s authority and responsibility for the medical school and its educational program?  Evaluate whether the dean has appropriate access to university and other officials, so as to support his or her ability to carry out these defined responsibilities. (2.2, 2.3)

A medical school has in place a sufficient number of associate or assistant deans, leaders of organizational units, and senior administrative staff who are able to commit the time necessary to accomplish the missions of the medical school.