Accreditation and Continuous Quality Improvement

Purpose

The Continuous Quality Improvement Steering Committee (CQISC) is charged to monitor compliance with the Liaison Committee on Medical Education (LCME) accreditation standards and elements. In an ongoing effort to improve the M.D. program and the learning environment, the CQISC will also ascertain both long- and short-term goals, implement a systematic process to collect and review data, and disseminate outcomes to appropriate leadership and administration, including, but not limited to, the Faculty Curriculum Committee (FCC), the Admissions Committee, the Executive Committee, various assistant/associate deans, and department chairpersons. The CQISC will also collaborate with leadership and administration to identify action plans to achieve goals, as evidenced by measurable outcomes.

CQI Steering Committee (CQISC) Members

Brenda Roman, M.D. – Associate Dean of Medical Education, chair
Colleen Hayden, M.S. – Director of Medical Education & Accreditation
Gary LeRoy, M.D. – Associate Dean of Student Affairs & Admissions
Al Painter, Psy.D. – Associate Dean of Faculty & Clinical Affairs
Kimberly Paul, M.H.A. – Chief Administrative Officer
Eric Bennett, Ph.D. – NCBP department chair (FCC, Executive Committee rep)
Randy Welton, M.D. – Psychiatry residency director (GME rep)
Paul Koles, M.D., Pathology department chair
Two student representatives, appointed by the Dean of Medicine (M2 and M3)

CQI Working Group Members

Colleen Hayden, M.S. – Director of Medical Education & Accreditation, chair
Lori Martensen, M.S. – Director, Wright Rural Health Initiative
Kelly Rabah, M.S.W. – Director PSQI, BSOM
Greg Kojola, M.B.A. – IT Representative

CQISC Duties & Responsibilities

  • Determine accreditation elements to be reviewed and monitored on an annual basis. Reasons for monitoring may include, but are not limited to, national trends, elements cited in previous full surveys, identified areas of needed improvement, etc.
  • Share outcomes and recommendations to leadership and administration. Collaborate and coordinate efforts to develop, achieve, and maintain goals.

CQI Working Group Duties & Responsibilities

  • Oversee the development of a data collection and management system.
  • Maintain a system of monitoring elements, which includes a formal review process entailing the development of recommendations, timelines, and goals.
  • Regularly review data sources that include internal end-of-year evaluations, AAMC Graduation Questionnaire (GQ), student/faculty evaluations, AAMC Mission Management Tool, assessment outcomes, aggregated USMLE scores, and other internal data sources as deemed appropriate by the CQISC.
  • Review and ensure policies, bylaws, committee membership, and affiliation agreements are systematically monitored and updated.

Meetings

CQI Steering Committee meetings should be held quarterly with at least four meetings occurring each academic year (July-June). Meeting agendas/minutes will be kept on file in the Office of Medical Education.

The CQI Working Group will meet on a monthly basis to regularly monitor compliance with LCME standards/elements and update the LCME CQI Dashboard. The CQI Working Group will provide updated action plans and outcome reports at the quarterly CQISC meetings.

An annual strategic retreat will be held each fall to provide the CQISC with a comprehensive overview of the current state of the LCME standards/elements, with recommendations from the CQI Working Group as to which standards/elements need attention during the upcoming year.

Organization

The CQISC members are appointed by the dean of medicine, with the membership reviewed annually. The CQISC functions in an advisory and collaborative role with leadership and administration. While the CQISC makes recommendations to various committees, those committees have the final authority and responsibility for enacting the obligations of that committee, and the CQISC will not infringe upon the autonomy and authority of other committees, including, but not limited to the FCC, the Admissions Committee, and the Executive Committee. However, the spirit and function of the CQISC is to hold the entire medical school team accountable for continual improvement of the M.D. program. While preparing for an LCME site review, the CQISC will serve as the LCME Steering Committee.

Approved by Executive Committee: 9/14/2017

Adapted from Emory University School of Medicine and West Virginia University School of Medicine LCME CQI processes.


GME and CME Accreditation

Graduate Medical Education, ACGME-accredited residencies and fellowships
Continuing Medical Education, awarded ACGME Accreditation with Commendation

Last edited on 10/11/2018.