Continuous Quality Improvement for the Medical Education Program

Effective Date: 07/25/2025

To Whom this Policy Applies

The policy applies to the medical education program.

Who Needs to Know This Policy

Faculty and senior administrative staff.

Purpose/Background

This policy establishes the framework and procedures for the medical school’s Continuous Quality Improvement (CQI) processes. It ensures that the medical education program systematically monitors, evaluates, and enhances its compliance with the Liaison Committee on Medical Education (LCME) accreditation standards and fosters a culture of excellence, accountability, and data-informed decision-making.

Policy

The University of Nevada, Reno School of Medicine (UNR Med) will engage in a process of Continuous Quality Improvement (CQI) to promote UNR Med’s fulfillment of its mission to achieve excellence in education, clinical care, biomedical and behavioral research. The CQI process will establish short and long-term programmatic goals, resulting in the achievement of measurable outcomes that are used to improve educational program quality, and promote effective monitoring of the medical education program’s compliance with accreditation standards.

UNR Med will maintain and implement a plan in which a subset of LCME elements will be systematically monitored.

Definations

Continuous Quality Improvement: A systematic approach to the analysis of performance and efforts to improve performance. In addition, the LCME describes CQI as a process both to monitor compliance with accreditation standards in the interval between full accreditation reviews and to act on the results.

Goal: A specific result or statement of what the institution will achieve. Goals should be specific, measurable, and achievable.

Responsibilities & Procedures

1. Responsibilities
   1. Office of Continuous Institutional Assessment (OCIA)/Assistant Dean for Institutional Assessment and Accreditation:
      • Develops, implements, and revises the CQI monitoring plan and disseminates results.
      • Coordinates the collection, analysis, and presentation of CQI-related data.
      • Maintains a current mapping of LCME elements to relevant data sources and responsible parties.
      • Maintains the official history and records of LCME elements being monitored.
      • Supports committee activities and liaises with institutional leadership and relevant offices.
      • Reports findings and recommendations to the Dean.
   2. CQI Committee
      • Monitors compliance with all LCME accreditation standards and elements.
      • Identifies areas at risk for non-compliance or suboptimal performance.
      • Collaborates with the Assistant/Associate Dean for Institutional Assessment and Accreditation to develop and monitor improvement plans.
      • Assigns each LCME element being monitored a risk level (Tier).
      • Reviews progress toward CQI goals and adjusts plans as needed.
2. Procedures

1. 1. For each metric that will be monitored, the following components must be included in the CQI monitoring plan:
      • LCME element number (as applicable)
      • Risk level (Tier)
      • Timing of monitoring
      • Data used to monitor the element
      • Benchmarks used to monitor improvement
      • The individual(s) or group(s) responsible for data collection, analysis, and reporting
      • The individual(s) or group(s) who will receive the results
      • The individual(s) or group(s) responsible for acting
      • Short and long-term goals, if the element is the focus of quality improvement efforts
   2. Reporting Requirements
      The OCIA will maintain a record of the review of each element included in the CQI plan. If there are concerns with the quality and/or compliance, the OCIA will work with the group responsible for taking action to develop a plan for improvement.
      An annual CQI Report will be produced by the OCIA. It will be disseminated for discussion to relevant stakeholder(s)groups including, but not limited to the UNR Med Executive Committee and the Medical Education Steering Committee (and subcommittees).
   3. Updating and Revising the CQI Plan
      The OCIA will review and revise the CQI monitoring plan no less frequently than every 2 years. The elements that are included will be updated based upon changes to the LCME's Standards and Elements, changes to the medical education program, and the current best practices.

Review

Approved by UNR Med Executive Committee, 06/04/2025