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.

Related LCME Standards

1.1: Strategic Planning and Continuous Improvement

Principles

  1. 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.
  2. 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 review process and calendar is overseen by the Chief of Staff, Office of Medical Education, Manager, Curriculum Governance,  and Director of Program Evaluation and supported by the Manager, Educational Evaluations unit.  Data is provided by the Educational Evaluations Unit and Technology Enhanced Education Unit’s data team.

See attached grid.

Procedures

1. The Chief of Staff for the Office of Medical Education is responsible for monitoring the accreditation review calendar.

2. The Director, Program Evaluation, and Manager, Educational Evaluations determine the content and design of the reports, and distribute reports based on calendar. 

3. The Manager, Curriculum Governance maintains the curriculum governance agendas and ensures that standards are reviewed based on the governance calendar.

 

Summary:

Accreditation Element

6 mos.


Annually 

2 yrs.

4 yrs.

Governance Review

Operational Ongoing Review

1.1 Strategic and Continuous Review

 

 

 

x

Committee on Curriculum and Educational Policy

Administrative Director, OME

1.5 By-Laws

 

 

 

x

Committee on Curriculum and Educational Policy

Administrative Director, OME

1.4 Affiliation Agreement

 

 

 

x

Foundations 2 Operations

OME, Administrative Director reviews expiring agreements on an annual basis.

2.4 Sufficiency of Staff (AAMC GQ)

 

x

 

 

Committee on Curriculum and Educational Policy

Education’s Dean Council

3.3 Diversity/Pipeline Programs (Pipeline data)

 

 

x

 

Committee on Curriculum Educational Policy

School of Medicine Differences Matter

3.5 Learning Environment/ Professionalism

 

x

 

 

Bridges Executive Committee

 

3.6 Student Mistreatment

x

 

 

 

Foundations 2 Operations (clerkship directors)

Associate Dean for Students receives and responds to mistreatment reports in real-time.

 

 x

 

 

Committee on Curriculum and Educational Policy

 

5.1 Adequacy of Financial Resources

 

x

 

 

School of Medicine Dean’s Council

 

6.1 Program and Learning Objectives (YODA dissemination)

 

x

 

 

Bridges Executive Council

Associate Dean for Curriculum

6.1 Program Objectives Review

 

 

 

 x

Committee on Curriculum and Educational Policy

 

6.2 Required Clinical Experiences

(patient type/procedure skills/student responsibility)

 

 

x

 

Foundations 2 Operations

 

6.3 Self Directed Learning (pre-clerkship student workload)

 

 

x

 

 

Foundations 1 Operations

 

6.4 Inpatient/Outpatient Experiences

        (%Ambulatory/%Inpatient)

 

 

x

 

Foundations 2 Operations

 

8.2 Use of Medical Program Objectives (Competency mapping)

 

x

 

 

Bridges Executive Committee

 

8.3 Curricular Design, Review, Revision, Content Monitoring

 

 

 

x

Committee on Curriculum and Educational Policy

Course and clerkship reviews are conducted annually by the Education Evaluations team and reviewed by the 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

 

USMLE outcomes are reviewed by Executive Committee and Operational Committees

8.6 Monitoring Completion of Required Clinical Experiences

(Clinical Encounter where alternative methods used by 25%

of students)

 

x

 

 

Foundations 2 Operations (Clerkship Directors)

 

8.7 Comparability of Education Assessment (clerkship reports)

 

 x

 

 

Foundations 2 Operations (Clerkship Directors)

 

8.8 Monitoring Student Workload

x

x

 

 

Bridges Executive Committee

Associate Dean for Curriculum reviews duty hours violations as reports are received. 

9.1 Residents and Non-Faculty Teachers (distribution of objectives and orientation)

 

x

 

 

Committee on Curriculum and Educational Policy

 

 

9.2 Faculty Appointments   x     Foundations 2 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 2 Operations
Foundations 1 Operations

11.2 Career Advising

 

x

 

 

Committee on Curriculum and Educational Policy 

 

12.0 Financial Aid/Debt Management (AAMC GQ)

 

x

 

 

Committee on Curriculum and Educational Policy

 

Education Dean’s Council

12.3 Personal Counseling/Well-Being Programs

 

x

 

 

Committee on Curriculum and Educational Policy

 

Education Dean’s Council

12.4 Student Access to Health Care Services

 

x

 

 

Committee on Curriculum and Educational Policy

Education Dean’s Council

 

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

Last Updated: October 30, 2018