LCME Element 1.1 – Focusing on Continuous Quality Improvement
A medical school engages in ongoing strategic planning and continuous quality improvement processes that establish its short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve educational program quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards.
Hidden Curriculum
This element is one of the most frequently cited by the LCME and is probably the most important element in the DCI due to its frequent occurrence within elements, whether overtly stated or subtly embedded in the hidden curriculum of the LCME. It is 1.1 after all!
The goal of this element is to promote a way of tangibly demonstrating you regularly collect data and organize it in a way that it is informative and actionable for strategic planning and/or for the purposes of Continuous Quality Improvement (CQI) for accreditation.
Effectively utilizing actionable information depends on a thorough analysis of your institution’s overall structure and function. A well-informed investigation into the analysis of root causes becomes essential when pinpointing concerns through those processes and procedures. It’s important that the collected actionable information is analyzed by individuals with the authority to implement necessary actions.
Best Practice
Does your school have formalized processes for the monitoring of accreditation elements? One example of a formalized process is having a Continuous Quality Improvement Policy. The policy should address the continuous improvement of the quality of your medical education program. How is this commitment demonstrated? By diligently implementing continuous quality improvement processes, which should be designed to establish short and long-term programmatic goals, facilitate achievement of measurable outcomes, and ensure effective monitoring of your medical education program in compliance with accreditation standards. You should also consider including in the policy who has core responsibility for and authority to manage the CQI effort at your school. Remember that many of the elements fall outside the scope of an OME office, so think carefully about who has the gravitas to interact with finance, faculty affairs, faculty development etc. The policy should also describe who manages the process, who is responsible for elements, who receives data and who acts on the data. Having such a policy communicates a clear message to the school, emphasizing the importance of implementing formalized processes and allocating dedicated resources. It’s important to note that you don’t have to have a CQI committee. Nothing in the element specifies this need. You do need to have a process.
The accreditation process, which occurs in an 8-year cycle, often follows a pattern where it may be overlooked for a period. For example, if your site visit is six years away, there may be a tendency to neglect or overlook the CQI process, dismissing its immediate importance based on the relatively distant timeframe until the next self-study. Do not leave CQI to chance or memory! You don’t want to leave it to any group either (e.g., Assessment team, Curriculum Committee or Deans) to remember what needs to be done. Make it easy on yourself. Have a plan to continuously monitor LCME elements such as reviewing each element every two years for quality assurance through educational leadership retreats and executive leadership meetings for non OME elements. If you plan to review all elements every two years, keep in mind that some elements require more frequent reviews for CQI purposes. There is a lengthy list of elements that should be monitored for CQI on an ongoing basis (monthly, quarterly, and/or annually). Elements monitored more frequently include, but are not limited, to:
- Elements that include language that monitoring is required or involve a regularly occurring process that may be prone to slippage.
- New elements or elements where LCME expectations have evolved.
- Elements that include policies that must be congruent with current operations.
- Elements that directly or indirectly affect the core operations of the school.
- Standards/elements that were cited in the medical schools’ previous full survey.
- Elements up for review or on an as needed basis.
When it comes to “Table 1.1-1 Monitoring process for each selected element” – a frequent question is – Do we need to include all 93 elements? Well, that depends on your school. Building this table out can be one of the hardest things to do. Nevertheless, most schools often rely on platforms like Excel to develop CQI planning tools or crosswalks. These tools enable a comprehensive examination of each element, understanding the intent behind them, and establishing criteria for monitoring. Factors such as previous citations for the school, frequently cited by the LCME, and the necessity of specific policies play a crucial role in determining the monitoring process. You always want to keep up to date on your policies which in and of themselves should be on a specific review cycle. In alignment with the table, it is essential to identify the groups responsible for taking action, those designated to receive the data, and incorporate the frequency of these actions. This comprehensive approach ensures a well-organized and systematic handling of information and responsibilities within the specified framework.
Continuous Quality Improvement
Schools are required to show evidence of taking action on measurable outcomes. If the outcomes fall short, there is an expectation to outline the corrective actions being implemented and demonstrate the utilization of Continuous Quality Improvement (CQI) processes in addressing the situation. The LCME provides us with a white paper on element 1.1 (Implementing a System for Monitoring Performance in LCME Accreditation Standards) that can be a useful CQI guidance document.
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