College of Medicine:Continuous Quality Improvement Policy

It is the policy of the UNMC College of Medicine (COM) to engage in the process of continuous quality improvement (CQI) of all UME educational programs through the regular review, monitoring and subsequent optimization of policies, procedures and outcomes with the goal of achieving our stated mission, strategic goals and compliance with accreditation standards.

Specific CQI initiatives should focus on the UME programs:

• Alignment with institutional initiatives, strategic goals and requirements
• Response to changes in resources, infrastructure and other administrative needs
• Incorporation of advances in proven educational practices
• Compliance with accreditation standards

Accomplishing the goals outlined in the CQI policy is the operational responsibility of the COM UME administrative leadership and will be operated by the Administrative Oversight and Quality Committee (AOQC), which will focus on infrastructural, operational and strategic needs with assistance by the COM Accreditation Sub-Committee and other administrative bodies as warranted.

Administrative Oversight and Quality Committee (AOQC)

The AOQC is responsible for ensuring the ongoing quality and optimization of the operational, strategic, relational and infrastructural needs of the College in support of the undergraduate medical education program.  To do so, the AOQC has the authority to request and review data, reports and information from available sources, advocate for change and action, as part of an ongoing quality improvement process.

The AOQC does not directly oversee any specific COM leadership role or standing committee but does have the authority to task individuals. committees or other COM-related bodies to investigate and act upon specific issues and request reports or updates with regards to progress and outcomes.  Current COM Standing Committees will continue to have monitoring, oversight and decision-making authority within their stated scope.

The Associate Dean for Learning Environment and Educational Strategy will serve as Chair of the AOQC and the membership consists of the administrative leadership of the UME program (i.e., Associate Dean for Medical Education; Associate and Assistant Dean for Student Affairs; Senior Associate Dean for Business and Finance;  Chair and Vice-Chair of the Curriculum Committee).  Other key leaders from the COM and elsewhere will be invited to review specific topics as they arise in the review process.  The AOQC reports directly to the Dean, College of Medicine and meets at least on a monthly basis.  

Accreditation Sub-Committee (ASC)

The ASC is a crucial aspect of the COM continuous quality improvement process and supplements the overarching function of the AOQC.  Its specific purpose is to ensure COM compliance with current and evolving LCME Standards and Elements, develop preliminary documentation and narrative comments within accreditation documents and make recommendations/requests to the AOQC to ensure COM ongoing alignment with accreditation standards.

The Associate Dean for Medical Education, who has responsibility for ongoing accreditation, will serve as Chair of the Accreditation Sub-Committee and the membership will consist of chairs of each of the Accreditation Review Task Forces which are appointed by the Dean.  These Task Forces, one for each LCME Standard, compile data associated with their assigned Standard and related Elements to identify gaps and make recommendations to the ASC for consideration.  At least yearly, the ASC will submit a summary of accreditation compliance data with evaluation of that data and any recommendations needed regarding improvement to the AOQC for action.  The AOQC is responsible for ensuring that appropriate resources are available for these activities.

Data Monitoring & Reporting

The AOQC will maintain a continuous project plan that includes the scheduled review of key accreditation standards identified by the ASC and other the operational, strategic, relational and infrastructural needs identified by College leadership or the faculty.  Specific sources of data for focused monitoring and CQI will include, but are not limited to, the following:

• LCME Elements that have been cited as “unsatisfactory” or “satisfactory with need for monitoring” during previous LCME accreditation visits
• LCME Elements that are new or in which LCME expectations have evolved (e.g., communicated through AAMC meetings, LCME website or other communication from the secretariats) as identified by the Associate Dean for Medical Education and/or the ASC
• LCME Elements affected by changes to UNMC or COM policies
• LCME Elements that explicitly require regular monitoring or relate to regularly occurring processes per LCME, UNMC or COM policies
• Other items identified through the UME program evaluation process (e.g., institutional or national surveys, block reports and curricular mapping) or brought forward by the Curriculum Committee, Faculty Council, etc. or COM senior leadership as areas of concern from the faculty or students that need evaluation, monitoring or action for optimization.
• Strategic growth and engagement initiatives (e.g., diversity, equity and inclusion, international engagement, community engagement, iEXCEL utilization, NU Foundation engagement, enhancement of student organizations) that support the mission of the COM and UNMC.

The AOQC will develop and maintain a project plan that will include areas for monitoring and/or improvement, timing of follow-up and data sources used for monitoring.  The outcomes of data review and discussion will include all necessary action steps including time for follow-up and the person/group responsible for the action.  This project plan is to be presented at least semi-annually to the Curriculum Committee and Faculty Council and as requested.

Approved by the College of Medicine Dean: November 25, 2020

Revised: May 20, 2021

Approved by Curriculum Committee: May 25, 2021

Approved by Faculty Council: July 9, 2021