University of California San Francisco
UCSF School of Medicine UCSF Medical Center

Continuous Quality Review Policy

Purpose

To outline the continuous process for monitoring the outcomes of the education program and the Liaison Committee on Medical Education (LCME) accreditation elements to improve the quality of the UCSF School of Medicine medical education program. 

Overview

UCSF Office of Medical Education is dedicated to continuously improving the quality of its medical education program and ensuring effective monitoring of the program’s compliance with accreditation standards. The UCSF Medical Education Program engages in ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve programmatic quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards. This policy outlines the timing of reviews and the minimum expectations for the review of each element. 

Related LCME Standards

1.1 Strategic Planning and Continuous Improvement 

Policy

  1. The UCSF Medical Education program, overseen by the Committee on Curriculum and Educational Policy, has established continuous review expectations for programmatic goals, medical education outcomes, and all LCME standards and elements as defined below. Relevant expectations include the frequency of review and the individual or unit responsible for conducting the review. These expectations are summarized in this policy. 
  2. The Council for Education Continuous Quality Improvement (CECQI) is responsible for monitoring all accreditation standards and elements on a regular interval; identifying and synthesizing data relevant to the standards; presenting them to leadership, unit and/or governance committee; and recommending to the accountable leader actions to address deficiencies and implement improvement strategies. CECQI establishes measurable outcomes to track the effectiveness of interventions and support continuous improvement.
  3. The frequency of review of standards is as follows:
    1. Bi-annual or more frequent reviews are appropriate for selected standards impacting student wellbeing, learning environment, assessment, and trajectory through the curriculum; for new LCME standards; for standards for which UCSF was found not to be in full compliance; and for any standards for which LCME mandates review of this frequency. These selected standards are presented at curriculum governance on a regular basis. 
      1. At any time, the accountable associate deans and directors may request that data be brought to the attention of the relevant governance committees.
    2. Annual reviews conducted for all standards. 
    3. A review cycle of every four years is enacted for the overall curriculum.

Procedure

  1. Regular and ongoing educational program review and outcomes are overseen by the Associate Dean for Assessment, Improvement, and Accreditation and Director of Program Evaluation and Education Continuous Quality Improvement as noted in the Program Evaluation and Evaluations policies and procedures. 
  2. The Director of Program Evaluation and Education Continuous Quality Improvement (ECQI) appoints a Council on Continuous Quality Improvement (CECQI) to provide direction on the school’s ECQI initiatives and accreditation standards. The CECQI is co-chaired by the Director of Program Evaluation and Education Continuous Quality Improvement and the Manager for Education Evaluation and Education Continuous Quality Improvement. CECQI meets monthly and is a collaboration across multiple teams in Office of Medical Education.
  3. The CECQI maintains an element monitoring dashboard which includes, for each element, the frequency of review, the individuals or groups receiving the results, and the accountable dean. 
  4. Issues highlighted by the CECQI are raised to the relevant leaders, governance, and/or Educational Continuous Quality Improvement Leadership group, which is Co-Chaired by the Associate Dean for Assessment, Improvement, and Accreditation and the Director of Program Evaluation and Education Continuous Quality Improvement. The ECQI Advisory Group ensures that leadership, and all appropriate parties, are aware of relevant improvement processes and that improvement processes are adequately supported.  
  5. The Director of Program Evaluation and Education Continuous Quality Improvement, Director of Educational Data and Analytics, and Manager of Educational Evaluation and Education Continuous Quality Improvement determine the content and design of the evaluation data reports and ensure the timely and accurate distribution of reports based on the governance calendar. 
  6. The Accreditation Program Manager and Coordinator of Curriculum Governance and Clinical Affiliations maintain the curriculum governance agendas and ensure that standards required for regular review at Curriculum Governance are reviewed based on the curriculum governance calendar. 
     

Accountable Dean or Director:
Associate Dean for Assessment, Improvement, and Accreditation

Related Policies

1.  Program Evaluation Policy

2. Evaluation Procedures

Approval Date and Governing Body: August 1, 2017, CCEP

Last Updated: July 08, 2025