Continuous Quality Review Policy
Purpose
To outline the Liaison Committee for Medical Education accreditation elements that the medical education program will monitor on an ongoing basis to continuously improve the quality of its medical education programs.
Overview
UCSF Office of Medical Education is dedicated to continuously improving the quality of its medical education programs and ensuring effective monitoring of the program’s compliance with accreditation standards. The Office of Medical Education in partnership with the School of Medicine’s Dean’s Office will ensure that the following programmatic outcomes and accreditation elements will be reviewed on a regularly scheduled basis to ensure compliance with accreditation standards.
Principles
- LCME elements impacting student well-being and ongoing operations (student mistreatment, duty hour violations, mid-clerkship feedback, grade timeliness, course review) undergo an ongoing operational review. At any time, the accountable associate deans/directors may request that data be brought to the attention of the relevant governance committees outlined below.
- This policy outlines the minimum expectations that each element will be reviewed by governance committees.
Policy
1. The UCSF Medical Education program, in consultation with the CCEP has established continuous review expectations for critical LCME standards as defined below. Relevant expectations include the frequency of review, as well as the individual or unit responsible for conducting the review. These minimum expectations are summarized in the attached calendar.
2. The frequency of review of standards is as follows:
a. Annual or more frequent reviews are appropriate for standards impacting student wellbeing, 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.
b. Biannual reviews are appropriate for standards related to the conduct of the curriculum, including but not limited to curricular objectives, clinical experiences and other standards related to policies or elements that impact the core operations of the school.
c. A review cycle of every four years is appropriate for overall curricular design.
3. The Director for Educational Continuous Quality Improvement (ECQI) is responsible for monitoring accreditation standards; identifying and synthesizing data elements relevant to the standards; presenting them to the relevant governance committee; and working with the accountable leader to address deficiences and implement improvement strategies.
See attached grid.
Procedures
1. The Director of ECQI appointed a Council on Continuous Quality Improvement (CECQI) to provide direction on the school's ECQI initiatives, strategic goal and accreditation standards.
2. The Director, Educational Continuous Quality Improvement collaborates with the Chief of Staff for the Office of Medical Education to monitor the accreditation review calendar. The Chief of Staff oversees instiutional response to reporting authorities (UCOP, USNWR, LCME) and project manages the curriculum governance and LCME reaccreditation process.
3. The Director, ECQI and Director, Educational Data and Analtyics and Manager, Educational Evaluations determines the content and design of the reports, and ensure timely and accurate distribution of reports based on the calendar.
4. The coordinator, clinical affiliations and curriculum quality maintain the curriculum governance agendas and ensures that standards are reviewed based on the curriculum governance calendar.
Summary:
|
Accreditation Element |
6 mos. |
|
2 yrs. |
4 yrs. |
Individual/Groups Receiving Results |
Individual Responsible for Taking Action |
|
1.1 Strategic and Continuous Review |
|
|
|
x |
Committee on Curriculum and Educational Policy Dean, Executive Dean/Vice Dean for Education |
Executive Vice Dean |
|
1.4 Affiliation Agreement |
|
|
|
x |
Foundations 2 operations |
Vice Dean for Education |
|
1.5 By-Laws |
|
|
|
x |
Committee on Curriculum and Educational Policy |
Vice Dean for Education |
|
2.4 Sufficiency of Staff (AAMC GQ) |
|
x |
|
|
Committee on Curriculum and Educational Policy Education Deans Council |
Vice Dean for Education |
|
3.3 Diversity/Pipeline Programs (Pipeline data) |
|
|
x |
|
Committee on Curriculum Educational Policy |
School of Medicine Differences Matter |
|
3.5 Learning Environment/ Professionalism |
|
x |
|
|
Committee on Curriculum and Educational Policy Bridges Executive Committee Education Associate Deans Council |
Vice Dean for Education |
|
3.6 Student Mistreatment |
x |
|
|
|
Bridges Executive Committee Foundations 1 Operations Foundations 2 Operations (clerkship directors) Career Launch |
Associate Dean for Students |
|
|
x |
|
|
Committee on Curriculum and Educational Policy Department Chairs |
Associate Dean for students |
|
|
5.1 Adequacy of Financial Resources |
|
x |
|
|
Dean Office of Medical Education Budget Committee |
Vice Dean for Education |
|
6.1 Program Objectives Review |
|
|
|
x |
Committee on Curriculum and Educational Policy |
Associate Dean for Assessment |
|
6.2 Required Clinical Experiences (patient type/procedure skills/student responsibility) |
|
|
x |
|
Department Chairs Foundations 2 Operations |
Associate Dean for Curriculum |
|
6.3 Self Directed Learning (pre-clerkship student workload)
|
|
x |
|
|
Bridges Executive Committee Foundations 1 Operations |
Associate Dean for Curriculum |
|
6.4 Inpatient/Outpatient Experiences (%Ambulatory/%Inpatient) |
|
|
x |
|
Foundations 2 Operations Education Deans Council |
Associate Dean for Curriculum |
|
8.2 Use of Medical Program Objectives (Competency mapping) |
|
x |
|
|
Bridges Executive Committee Education Deans Council |
Associate Dean for Curriculum |
|
8.3 Curricular Design, Review, Revision, Content Monitoring |
|
|
|
x |
Committee on Curriculum and Educational Policy
Mapping and Integration Committee |
Associate Dean for Curriculum |
|
8.3 Curricular Content Monitoring |
|
|
x |
|
Bridges Executive Committee |
Mapping and Integration Committee reviews content reports. |
|
8.4 Program Evaluation |
|
x |
|
|
Committee on Curriculum and Educational Policy Bridges Executive Committee Foundations 1 Operations Foundations 2 Operations Department Chairs
|
Vice Dean for Education USMLE outcomes are reviewed by Executive Committee and Operational Committees and CCEP respectively. |
|
8.6 Monitoring Completion of Required Clinical Experiences (Clinical Encounter where alternative methods used by 25% of students) |
|
x |
|
|
Foundations 2 Operations (Clerkship Directors) Department Chairs |
Associate Dean for Curriculum |
|
8.7 Comparability of Education Assessment (clerkship reports) |
|
x |
|
|
Department Chairs Foundations 2 Operations (Clerkship Directors) Career Launch Operations Education Deans Council |
Associate Dean for Curriculum |
|
8.8 Monitoring Student Workload |
|
x |
|
|
Bridges Executive Committee Foundations 1 Operations Foundations 2 operations Department Chairs |
Associate Dean for Curriculum |
|
9.1 Residents and Non-Faculty Teachers (distribution of objectives and orientation) |
|
x |
|
|
Committee on Curriculum and Educational Policy Department Chairs (as needed) Foundations 2 Operations |
Associate Dean for Curriculum Associate Dean for Graduate Medical Education |
| 9.2 Faculty Appointments | x |
Department Chairs Foundations 2 Operations Career Launch Operations |
||||
|
9.4 Observation of Clinical Skills (clerkship reports) |
|
x |
|
|
Foundations 2 Operations |
|
|
9.7 Formative Assessment and Feedback |
|
x |
|
|
Bridges Executive Committee |
Foundations 2 Operations |
|
9.8 Fair and Timely Summative Assessment |
|
x |
|
|
Bridges Executive Committee Foundations 1 Operations Foundations 2 Operations Department Chairs |
Associate Dean for Assessment |
|
11.2 Career Advising |
|
x |
|
|
Committee on Curriculum and Educational Policy Co-Directors, Career Advising Foundations 2 Operations Education Deans Council |
Associate Dean for Students |
|
12.0 Financial Aid/Debt Management (AAMC GQ) |
|
x |
|
|
Committee on Curriculum and Educational Policy Dean, School of Medicine Education Deans Council
|
Vice Dean for Education |
|
12.3 Personal Counseling/Well-Being Programs |
|
x |
|
|
Committee on Curriculum and Educational Policy Education Deans Council |
Associate Dean for Students |
|
12.4 Student Access to Health Care Services |
|
x |
|
|
Committee on Curriculum and Educational Policy Education Deans Council |
Associate Dean for Students |
Accountable Dean or Director: Associate Dean for Assessment, Improvement, and Accreditation
Approval Date and Governing Body: August 1, 2017, CCEP
Last Updated: October 30, 2020
