Strategic & Continuous Quality Improvement Policy

Overview/Rationale

Vagelos College of Physicians & Surgeons is dedicated to continuous improvement of the quality of its programs. This commitment is demonstrated through ongoing planning and continuous quality improvement processes, which are designed to establish short and long-term programmatic goals, facilitate achievement of measurable outcomes, and ensure effective monitoring of all programs in compliance with applicable accreditation standards. 

Accreditation Standards

LCME Accreditation Standards: 

Standard 1: Mission, Planning, Organization, & Integrity 

A medical school has a written statement of mission and goals for the medical education program, conducts ongoing planning, and has written bylaws that describe an effective organizational structure and governance processes. In the conduct of all internal and external activities, the medical school demonstrates integrity through its consistent and documented adherence to fair, impartial, and effective processes, policies, and practices. 

1.1 Strategic Planning and Continuous Quality Improvement 

A medical school engages in ongoing strategic planning and continuous quality improvement processes that establish its short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve educational program quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards. 

Stakeholders

This policy applies to the Executive Vice President for Health and Biomedical Sciences and Dean of the Faculties of Health Sciences and Medicine, as well as faculty and staff working in the Office of the Dean, Office of Education, and other VP&S (Vagelos College of Physicians & Surgeons) departments that participate in strategic planning or continuous quality improvement activities on behalf of VP&S. VP&S personnel implement this policy, consulting with VP&S Office of the Provost as necessary to maintain alignment with the mission and strategic plans of the institution. 

Definitions 

• VP&S – Vagelos College of Physicians & Surgeons 
• Continuous Quality Improvement (CQI) – method(s) by which operational problems are identified, interventions are designed and initiated, outcomes are monitored for effectiveness, and best practices are replicated. 
• Data Collection Instrument (DCI) – a template that the LCME provides to medical schools for the purpose of guiding internal evaluation of their medical education programs according to applicable accreditation standards. The DCI includes questions, prompts, tables, and supplemental requests for information that VP&S MD program must complete and submit for LCME review during the accreditation process. 
• LCME – Liaison Committee on Medical Education 

Strategic Plan Requirements 

1. Accreditation Compliance. The VP&S will establish a system to monitor the medical school’s ongoing accreditation compliance with LCME standards and elements. The system will yield an accurate view of current M.D. Degree Program operations; help VP&S personnel identify action items required for accreditation; anticipate challenges to implementation of new or updated standards or elements, as may be required by the LCME to enhance the quality of the education program leading to the M.D. Degree; and mitigate risks of accreditation noncompliance through ongoing communication and coordination with the Office of the Dean and the Office of Education. 
2. Data Collection and CQI Monitoring. Strategic plan revisions must be informed by experiences and data collected through CQI monitoring and any other relevant data. Data will be shared with individuals involved in the monitoring of current strategic plan metrics or revision of the strategic plan to facilitate the development of data-driven goals, metrics, and targets, and to promote quality improvement and innovation. Each CQI initiative will have goals with defined metrics and objectives for measuring progress. 
3. Performance Metrics. Performance metrics may be process-based or outcome-based. For each strategic plan metric, the VP&S will identify the individual(s)/group(s) responsible for implementation and tracking of objectives/goal completion, and subject matter experts (e.g., individuals, school committees, institutional committees) that should be consulted and/or informed regarding implementation and outcomes. 
4. Strategic Plan Monitoring & Revision 
   1. The Executive Vice President for Health and Biomedical Sciences and Dean of the Faculties of Health Sciences and Medicine will monitor the progress of the strategic plan at least annually. 
   2. VP&S will update its strategic plan at least every 10 years. 

CQI Monitoring 

This CQI monitoring and documentation system facilitates broad communication and coordination among the VP&S’s functional units (such as the Dean’s Office, Offices of Curriculum Affairs, Faculty Affairs, Student Affairs, Admissions and Financial Aid) and the institution’s governing bodies to support successful implementation of new initiatives and improvements. It also enables data-driven decision making through systemic collection of documentation, which strengthens education program management and effective oversight of accreditation compliance. The Vice Dean for Education and their designee will establish and monitor completion of a comprehensive work-plan that includes the following information: 

1. Purpose of the CQI Initiatives identified for work-plan inclusion: 
2. A List of LCME Standards and Elements, VP&S will monitor for CQI and quality assurance. The list includes, but is not limited to: 
   1. Elements that state monitoring is required or involve a regularly occurring process that may be “prone to slippage.” 
   2. New Elements or those expected to evolve 
   3. Elements that require VP&S policy development or maintenance, which must be congruent with current operations; 
   4. Elements that directly or indirectly affect the core operations of the school 
   5. Standards and elements that were cited in previous VP&S full surveys; and  
   6. Elements due for LCME scheduled review 
      The work plan may be revised to include additional standards and elements annually or as needed. CEPC (Committee on Educational Policy and Curriculum) must approve the removal of an element from monitoring.  
3. Data collection, including documentation of: 
   1. Data courses, 
   2. Schedule of data collection and review, 
   3. Individuals in designated organizational roles that are responsible for data collection,  
   4. Analysis, 
   5. Dissemination of Findings 
4. A list of individual(s) or group(s) who will receive data reports, determine action items, and initiate implementation (or assign a designee to implement) changes in the work-plan; recommend changes in the  VP&S strategic plan; and/or recommend changes in VP&S operations or policies to improve the quality of the education program and/or maintain accreditation compliance. 
   1. Designees responsible for reviewing the VP&S’s performance on a standard or element must develop recommendations and timelines for correction of identified deficiencies. When appropriate, recommended action plans will be approved by The Executive Vice President for Health and Biomedical Sciences and Dean of the Faculties of Health Sciences and Medicine, Vice Dean for Education, and/or VP&S Committees. 
   2. The Vice Dean, or their designee function as the is the liaison between Designees responsible for making recommendations and Designees responsible for implementing recommendations and ensures that approved actions and changes are made and that the resulting outcomes are documented and evaluated. 
   3. On a regular basis (e.g., at least annually), compliance results are summarized by the VP&S Office of Education and distributed to the The Executive Vice President for Health and Biomedical Sciences and Dean of the Faculties of Health Sciences and Medicine and VP&S Committees and others with accreditation responsibilities. 

The rationale for selecting elements for ongoing monitoring is described below: 

Responsibilities 

1. The Executive Vice President for Health and Biomedical Sciences and Dean of the Faculties of Health Sciences and Medicine over oversees all activities related to the strategic planning. The Executive Vice President for Health and Biomedical Sciences and Dean of the Faculties of Health Sciences and Medicine designates the Vice Dean for Education to oversee the accreditation of the M.D. program. They ensure that appropriate resources are allocated for these activities, including personnel, information technology systems, and infrastructure for the collecting and reporting of data. 
2. The Vice Dean for Education and the Office of Education will have core responsibility for and manage the CQI monitoring process of the MD program, including data used to monitor elements and monitoring timing. 
3. VP&S Standing Committees, VP&S Committees, and senior administrators within the school and the college contribute to the monitoring effort or at the request of the Executive Vice President for Health and Biomedical Sciences and Dean of the Faculties of Health Sciences and Medicine, and associated VP&S personnel provide coordination and support the CQI processes and DCI completion as needed. 
4. The Vice Dean for Education will articulate elements that need more than annual monitoring and who on the leadership team is responsible in consultation with the The Executive Vice President for Health and Biomedical Sciences and Dean of the Faculties of Health Sciences and Medicine.  

Procedures

This policy will be reviewed and revised as necessary, but at least every three years. The VP&S Strategic Plan for (specify span of time) is maintained by the Office of the Dean, and the CQI Monitoring work-plan is maintained by the Office of Education.  

Policy History:

The CQI Policy was taken from the Paper Documentation and online formats. These documents were reformatted and codified into policy where specific procedures and edits were added. The policy was reviewed and approved by the Committee on Educational Policy and Curriculum on June 21, 2024.