Quality Assurance and Continuous Quality Improvement Policy

Policy Statement

The Keck School of Medicine shall maintain a quality assurance (QA) and continuous quality improvement (CQI) program that regularly monitors the quality of the medical education program.  The program includes monitoring to assure that accreditation standards mandated by the Liaison Committee for Medical Education (LCME) are being met. Additionally, an ongoing set of quality improvement efforts to address areas of the medical education program identified by faculty, staff, and/or students as potential opportunities for advancement are monitored.

Policy Guidelines

1. The CQI Committee is charged with responsibility and authority to monitor the CQI processes of the medical school that includes the review of all relevant policies, programs, and processes to ensure the achievement of the mission and the effective monitoring of the program’s compliance with LCME accreditation elements and other appropriate standards.
2. The process to be used for monitoring LCME standards during the interval between full accreditation visits involves monitoring by the CQI Committee with reports to appropriate individuals or committees.
3. Standards or elements to be monitored include but are not limited to:
   • New elements or elements where LCME expectations have evolved
   • Elements that include policies that must be congruent with current operations
   • Elements that directly or indirectly affect the core operations of the school
   • Standards/elements that were cited in the school of medicine’s previous full survey
   • Additional elements that will undergo regular monitoring as part of annual program evaluation
4. Applicable standing committees receive the results of monitoring for analysis and review. The applicable senior leader is responsible for acting upon the results.
5. The senior leader/committee responsible for reviewing the performance in elements has a responsibility to develop recommendations and timelines for correction of identified deficiencies.
6. The Vice Dean for Medical Education or their designee acts as the liaison between senior leaders/committees responsible for making recommendations and those who will be responsible for carrying out the recommendations to ensure that specified corrections are made and that the resulting outcomes are evaluated.
7. Quality improvement projects with defined intervention(s) and outcome metrics may be proposed by individuals or groups of students and/or faculty/staff and submitted to the appropriate committee(s) for evaluation and approval.  Implementation of approved projects are conducted by the appropriate committee(s) and monitored by the CQI Committee with results and reports sent to the appropriate committee and the Vice Dean for Medical Education.

Reviewed and Approved: May 1, 2024

Medical Education Executive Council