/Institutions/University-of-Texas-Rio-Grande-Valley/json/som/policies-local.json

/Institutions/University-of-Texas-Rio-Grande-Valley/json/som/policies.json

EAA062 LCME Accreditation Standards Monitoring and Continuous Quality Improvement

Policy Number: EAA062
Policy Title: LCME Accreditation Standards Monitoring and Continuous Quality Improvement

A. Purpose

The University of Texas Rio Grande Valley (UTRGV) School of Medicine (SOM) is committed to excellence in education and to providing students with a comprehensive medical education that will promote their development as knowledgeable, skilled, and altruistic physicians. To meet this commitment and to adhere to Liaison Committee on Medical Education (LCME) standards, the UTRGV SOM will regularly monitor the LCME accreditation standards during the interval between accreditation visits.

B. Persons Affected

This policy will cover all UTRGV SOM faculty and staff.

C. Definitions

Continuous Quality Improvement (CQI): A structured planning approach that establishes short and long-term programmatic goals, results in the achievement of measurable outcomes that are used to improve programmatic quality, and ensures effective monitoring of the medical education program’s compliance with accreditation standards.

Liaison Committee for Medical Education (LCME): LCME is recognized by the U.S. Department of Education and the World Federation of Medical Education as the reliable authority for the accreditation of medical education programs leading to the MD degree.

D. Policy

The University of Texas Rio Grande Valley School of Medicine regularly monitors the accreditation standards of the Liaison Committee on Medical Education (LCME) during the interval between full accreditation visits for the purpose of continuous quality improvement of its medical educational program.

This policy meets the requirements of LCME Standard 1.1 (See Appendix A).

E. Procedures

   1. Authority and Responsibilities

The Associate Dean for Assessment and Quality Improvement (or his/her designee) and the Accreditation Review and Continuous Quality Improvement (ARCQI) Committee, with oversight of the Dean of the UTRGV SOM, are responsible for the implementation of this policy. The policy integrates the involvement of additional offices and functions of the School of Medicine, including, but not limited to, the Office of Student Affairs, the Office of Educational Affairs, and the Office of Faculty Affairs.

2. Role of the ARCQI Committee: The ARCQI Committee is responsible for regularly monitoring the accreditation standards of the LCME during the interval between accreditation visits for the purpose of continuous quality improvement of its medical education program. ARCQI Committee shall assure that benchmarks and measurements selected for monitoring are appropriate and measurable and shall provide monitoring and oversight of any action plans.

In addition, the ARCQI Committee will:

•  Address any existing or new elements where LCME expectations have evolved;
• Address elements that include policies that must be congruent with current operations;
• Address elements that directly or indirectly affect the core operations of the school;
• Address standards/elements that were cited in the SOM's previous LCME survey;
• Create a schedule for the review and monitoring of specific standards;
• Work with stakeholders to address priorities and risks related to the LCME elements under their purview;
• Work with subject matter experts to populate the LCME data collection instrument (DCI);
• Submit quarterly reports to the Dean on the activities of the committee;
• Submit an annual report summarizing the goals that were met by the committee, and an assessment plan setting the next year’s top priorities and outlining the goals set to attain those priorities.

The Assessment, Evaluation, & Quality Improvement (AEQI) team will serve as a resource for the ARCQI Committee.

  4. Confidentiality of Data

All data, especially faculty and student data, are de-identified and aggregated before submission to the ARCQI committee.

F. Relevant Federal/State Statutes, Board Regents, and/or Coordinating Board Rules

FERPA: Family Educational Rights and Privacy Act; 20 U.S.C. Sec. 1232g and 34 CFR Part 99

UT System Board of Regents Rule 50702: Confidentiality and Security of Education Records Subject to the Family Educational Rights and Privacy Act (FERPA)