Policy 122: Continuous Quality Improvement

Policy Number: 122

Date Approved: 08/06/2024

Executive Responsibility: Executive Committee

References: LCME Element 1.1

122.1 Purpose

In compliance with LCME Element 1.1, 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 that are used to improve programmatic quality and ensure effective monitoring of the BSOM medical education program’s compliance with accreditation standards.

122.2 Charge and Responsibilities

The Continuous Quality Improvement (CQI) Committee is responsible for monitoring compliance with the Liaison Committee on Medical Education (LCME) accreditation standards and elements. In an ongoing effort to improve the MD program and the learning environment, the CQI Committee 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, and various Associate Deans and Department Chairs. The CQI Committee also collaborates with leadership and administration to identify action plans to achieve goals, as evidenced by measurable outcomes.

The duties and responsibilities of the CQI Committee include:

• Determine timing of review and frequency of monitoring of specific accreditation elements. Reasons for monitoring may include, but are not limited to, national trends, elements cited in previous full surveys, identified areas of needed improvement, elements where LCME expectations have evolved, elements that require continuous monitoring that may be prone to slippage, etc.
• In compliance with timing and frequency of monitoring of elements, review LCME standards and elements and develop action items, including determining what person/group has responsibility over action plan.
• Regularly review data sources that include, but are not limited to, 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 CQI Committee functions in an advisory and collaborative role with leadership and administration. While the CQI Committee makes recommendations to various committees, those committees have the final authority and responsibility for enacting the obligations of that committee, and the CQI Committee 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 CQI Committee is to hold the entire medical school team accountable for continual improvement of the MD program.

122.3 Membership

As a Standing Committee of BSOM, per the faculty bylaws, the CQI Committee members are appointed by the Dean of Medicine. The membership includes broad representation from BSOM administration, faculty, and staff as well as two student representatives. Current membership can be found on the Faculty Affairs committees webpage.

122.4 Voting

All members of the CQI Committee are voting members of the committee.

122.5 Quorum

A quorum is at least 50% of the voting membership present. A quorum is required for all decisions requiring a vote of the committee.

122.6 Term

Membership is reviewed annually. Members are appointed by the Dean of Medicine.

122.7 Chair

The CQI Committee is chaired by the Associate Dean for Accreditation and Quality Improvement.

122.8 Meetings

CQI Committee shall meet at least four times each academic year (July-June). Meeting agendas/minutes are kept on file in the BAMS CQI Committee community.