EA-3110 Continuous Quality Improvement

1.0      Purpose

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. Allopathic medical schools accredited by the Liaison Committee on Medical Education (LCME) are expected to establish processes in strategic planning and ongoing continuous quality improvement to meet short- and long-term goals/outcomes, and to ensure ongoing monitoring of adherence to LCME standards.

2.0      Policy

The Continuous Quality Improvement (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. These standards 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. Specifically, the Committee:

• Reviews all LCME standards and elements on an ongoing basis.
• Identifies elements and establishes timelines for monitoring
• Evaluates monitoring and trends
• Recommends actions to address identify gaps or areas for further review
• Communicates with responsible stakeholders to support implementation of actions
• Monitors outcomes and implements actions

Maintains a centralized CQI dashboard outlining elements, data sources, processes, and responsible parties. The chair of the committee updates the Dean about the ongoing process and results of the committee on a regular basis. The chair, and ultimately the Dean, holds the authority for addressing needs and areas of concern identified in the process.

3.0      Procedures

The CQI Committee shall be comprised of participants from stakeholder groups who are involved with the undergraduate medical education program (e.g., faculty, decanal leaders, medical students, health system leadership, institutional staff).

Committee Meetings and Procedures

A core CQI operational group will meets regularly to review LCME elements, monitor progress, coordinate ongoing CQI activities, and identify areas requiring focused action.

The full CQI Committee will meet as needed to fulfill the duties of the committee charge. The Committee will:

• Use multiple data sources (e.g., annual reports, webinars, published materials, LCME information and videos) to stay updated on changes to LCME requirements
• Establish a timeline and review cycles for VTCSOM’s LCME standards and elements; the timelines and calendars will be reviewed and approved by the CQI Committee every two years
• Prioritize standards and elements that state an explicit requirement for monitoring, involve regularly occurring processes, pose potential concerns, merit timely reviews (e.g., are “prone to slippage,”), are new or recently revised, need review for alignment with current operations, or directly or indirectly affect the core operations of the School of Medicine
• Refer elements to the Faculty Accreditation Lead and Dean, as needed, for agreement on next-step interventions
• Evaluate reports generated by the review process to determine compliance with LCME standards

Committee members are responsible for escalating areas that require action to appropriate stakeholders at VTCSOM and assigning responsibility to specific individuals, requesting information or intervention related to areas of concern and/or areas of non-compliance, and developing timelines for addressing each concern

The Faculty Accreditation Lead (or designee) will provide updates to the Medical Curriculum Committee and other standing committees, as well as the Dean’s cabinet, two times per year or more frequently as needed.

4.0      References

• LCME White Paper Implementing a System for Monitoring Performance in LCME Accreditation Standards (2016).
• Hunt H, Migdal M, Waechter D, Barzansky B, Sabalis R. The Variables That Lead to Severe Action Decisions by the Liaison Committee on Medical Education. Academic Medicine. 2016; 91(1): 87-93

5.0      Approval and Revisions

Approved by the Medical Curriculum Committee on June 18, 2026