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Faculty and Clinical Affairs

Policy 23:  Continuous Quality Improvement

The Boonshoft School of Medicine (BSOM) is committed to ongoing planning and continuous quality improvement (CQI) processes that establish short and long-term programmatic goals resulting in the achievement of measurable outcomes.  These CQI processes are used to improve programmatic quality and ensure effective monitoring of the BSOM medical education program’s compliance with accreditation standards.

The Continuous Quality Improvement Steering Committee (CQISC) is responsible for monitoring 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 also ascertains both long- and short-term goals, implements systematic processes to collect and review data, and disseminates outcomes to appropriate leadership and administration, including, but not limited to, the Faculty Curriculum Committee (FCC), the Admissions Committee, the BSOM Executive Committee, The CQISC also collaborates with leadership and administration to identify action plans to achieve goals, as evidenced by measurable outcomes.

The CQISC members are appointed by the dean of medicine, with the membership reviewed annually and will include broad representation from BSOM administration, faculty, and staff as well as two student representatives (M2 and M3).  The CQISC will be chaired by the Associate Dean for Medical Education. The duties and responsibilities of the CQISC will include: 

  • 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.
  • 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.
  • Review and ensure policies, bylaws, committee membership, and affiliation agreements are systematically monitored and updated.
  • Share outcomes and recommendations to leadership and administration. Collaborate and coordinate efforts to develop, achieve, and maintain goals.

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 BSOM 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.

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 Department of Medical Education. 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. 

Approved by Executive Committee: 9/14/2017

Revised: 3/14/2019


Last edited on 06/23/2020.