Committee on Continuous Quality Improvement and LCME Standards
Virginia Tech Carilion School of Medicine
Purpose & Charge
Purpose
In 2016, and updated in 2025, the Liaison Committee on Medical Education (LCME), the organization that accredits all allopathic medical education programs in the U.S. and Canada, released the White Paper Implementing a System for Monitoring Performance in LCME Accreditation Standards, which outlined the necessity of accreditation monitoring. After analyzing factors influencing accreditation results, the LCME determined that conducting regular, ongoing performance reviews between accreditation visits would likely reduce the risk of unfavorable outcomes. As a result, schools were expected to establish processes in strategic planning and continuous quality improvement processes to support ongoing improvement, achievement of short- and long-term goals and outcomes, and monitoring of accreditation standards. LCME Elements 1.1 and 1.2 (Strategic Planning and Monitoring Performance in LCME Accreditation Elements– proposed for 2028-29) state that:
A medical school engages in an ongoing strategic planning process that establishes short- and long-term goals and evaluates progress toward achieving those goals through monitoring the achievement of measurable outcomes at defined time points (1.1) and that it engages in a process to monitor performance in LCME accreditation elements, correct identified deficiencies, and develop proactive approaches to improve educational program quality and outcomes (1.2).
CQI Committee Charge
The VTCSOM is committed to pursuing the highest excellence in the quality of the undergraduate medical education program, which requires regular review, reflection, and improvement upon processes and outcomes in the medical education program. The Committee on CQI and LCME Standards performs the primary function of these requirements, providing ongoing, effective monitoring of the undergraduate medical education program.
Charge. The CQI Committee is charged with ensuring the undergraduate medical education program at VTCSOM is operationally efficient and effective to meet the goals of the education mission.
The Committee coordinates, oversees, and ensures iterative improvement and regular review of compliance with LCME Standards and Elements. These Standards and Elements all relate to and are aligned with the VTCSOM undergraduate medical education program, specifically the leadership, administrative functions, budgeting and finance, curriculum, educational outcomes, and student services.
The Committee also coordinates school-level institutional effectiveness activities that support Virginia Tech’s accreditation by the Commission on Colleges and Universities (COCU), formerly SACSCOC. These activities may include review of student learning outcomes, administrative unit outcomes, program outcomes, strategic plan measures, and related improvement.
Specifically, the Committee:
- Performs the overall review of all LCME Standards and Elements
- Identifies the LCME Elements and the timing required for Routine and Focused Improvement and Monitoring
- Reviews the results of the monitoring
- Makes recommendations regarding actions needed to further explore or address needs
- Determines which individuals/groups should be responsible for taking action
- Regularly communicates/liaises with those individuals/group(s) responsible for making recommendations and those who will be responsible for carrying out the recommendations
- Monitors the outcomes of the actions
- Maintains an operational dashboard that describes the elements to be reviewed, data sources for each element, the process/procedures involved in managing CQI by Element, and the individuals/committees who will receive/act on the information
The Co-Chairs of the Committee (Associate Dean for Educational Affairs and Senior Director of Educational Affairs) update the Faculty Accreditation Lead and the Dean about the ongoing process and results of the CQI Committee on a regular basis. The Co-Chairs, in partnership with the Faculty Accreditation Lead and ultimately the Dean, hold the authority for addressing needs and areas of concern identified in the process.
Committee Structure and Membership
The CQI Committee membership is composed of the following members:
Core CQI Committee Members:
- Senior Associate Dean for Medical Education (Faculty Accreditation Lead)
- Associate Dean for Educational Affairs (Co-chair)
- Senior Director of Educational Affairs (Co-Chair)
- Associate Dean for Assessment, Evaluation, and Strategic Analytics
- Assistant Dean for Student Affairs
- Representative, Faculty Affairs
- Senior Director of Institutional Effectiveness and Accreditation
- Director of Digital Initiatives for Medical Education
- Manager, Assessment and Evaluation
- Manager, CQI and Curriculum
- Manager, Office of Educational Affairs
Committee Members:
- Vice Dean
- Associate Dean for Student Affairs
- Associate Dean for Admissions
- Interim Associate Dean for Faculty Affairs
- Senior Advisor for Faculty Affairs
- Associate Dean for Clinical Science
- Assistant Dean for Finance and Administration
- Director, Foundational Science Curriculum (Phase 1)
- Director of Clinical Clerkships (Phase 2)
- Director of UME-GME Transition (Phase 3)
- Associate Dean for Graduate Medical Education/Designated Institutional Official
- Senior Director, Enrollment Management and Assistant Registrar
- Medical Curriculum Committee Chair
- Two Dean-appointed faculty members of the medical school
- Student Representatives (across all classes)
- Student Curriculum Representatives (all classes)
The CQI Committee requires active participation of members from stakeholder groups who are involved with the undergraduate medical education program (e.g., faculty, medical students, health system leadership, institutional staff, etc.).
- Senior Associate Dean for Medical Education (Faculty Accreditation Lead)
- Leslie LaConte, Associate Dean for Educational Affairs (Co-Chair)
- Lee Rakes, Senior Director for Educational Affairs (Co-Chair)
- Brock Mutcheson, Associate Dean for Assessment, Evaluation, and Strategic Analytics; Chief Data Officer
- Emily Holt Foerst, Assistant Dean for Student Affairs and Director of Academic Counseling and Enrichment Services
- Dani Backus, Senior Director of Institutional Effectiveness and Accreditation
- Vianne Greek, Director of Digital Initiatives for Medical Education
- Caitlin Bassett, Manager, Assessment and Evaluation
- Kelli Fleming, Manager, CQI and Curriculum
- Alaina Guerry, Manager, Office of Educational Affairs
- Rebecca Pauly, Vice Dean
- Amanda Murchison, Associate Dean for Student Affairs
- Melanie Prusakowski, Associate Dean for Admissions
- Shari Whicker, Interim Associate Dean for Faculty Affairs
- Kemi Bankole, Senior Advisor for Faculty Affairs
- Tarin Schmidt-Dalton, Associate Dean for Clinical Science
- Sharon Barrett, Assistant Dean for Finance and Administration
- Renee Beirne, Director of Foundational Science Curriculum (Phase 1)
- Farrell Adkins, Director of Clinical Clerkships (Phase 2)
- Christi Stewart, Director of UME-GME Transition (Phase 3)
- Arthur Ollendorff, Associate Dean for Graduate Medical Education/Designated Institutional Official
- Tracy Jones, Senior Director of Enrollment Management and Assistant Registrar
- Jennifer Cleveland, Faculty Representative
- Sophia Keith, M1 Curriculum Representative
- May Khalid, M2 Curriculum Representative
- Neyha Baddigam, M1 Student Representative
- Sudev Namboodiri, M2 Student Representative
- Owen Ball, M3 Student Representative
- Tara Menon, M3 Student Representative
- Saif Pasha, M4 Student Representative
- Walker Welch, M4 Student Representative
- Jordan Peck, ISA Chair