Continuous Quality Improvement for the Medical Education Program

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

The University of Nevada, Reno School of Medicine will engage in a process of continuous quality improvement (CQI) to ensure that UNR Med fulfills its mission of excellence in education, clinical care, biomedical and behavioral research, and an institutional culture of respect, compassion and diversity. The CQI process of the LCME elements will establish 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.

Policy

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

Definations (as needed)

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 (Barzanksy et al., 2016).

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

Responsibilities & Procedures (as needed)

Responsibilities

The Office of Continuous Institutional Assessment (CIA) will develop, implement, and revise the CQI monitoring plan and disseminate results.

Procedures

CQI Monitoring

The CIA will develop and maintain a systematic CQI monitoring plan, implement the plan, and disseminate results no less frequently than once per year

Selection of Metrics to be Monitored

The CIA will monitor a subset of LCME elements. At minimum, the LCME elements that fall into one of the three categories below will be monitored. Additional elements may be included in the CQI plan.

• UNR Med Priorities: Elements that are the focus of current quality improvement efforts. These may be identified by the LCME or identified internally.

Best Practices: The CIA will review the literature to identify best practices for CQI and incorporate these best practices into the CQI plan. Required Components of the CQI Monitoring Plan
For each metric that will be monitored, the following components must be included in the CQI monitoring plan:

• LCME element number
• Timing of monitoring
• Data used to monitor the element
• The individual or group responsible for data collection, analysis, and reporting
• The individual(s) or group(s) who will receive the results
• The individuals/groups responsible for taking action
• Short and long-term goals, if the element is the focus of quality improvement efforts.

Reporting Requirements

The CIA 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 CIA will work with the group responsible for taking action to develop a plan for improvement.

Updating and Revising the CQI Plan

The CIA will review and revise the CQI monitoring plan no less frequently than every 3 years. The elements that are included will be updated based upon changes to the LCME's Standards and Elements, changes to medical education program, and the current literature.