Continuous Quality Improvement Policy

Policy Manual


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. CQI is a systematic approach to the analysis of institutional performance and efforts to improve performance. The UNR Med CQI process includes three key components that comprise a quality improvement feedback loop: 1) strategic plan development, 2) strategic plan implementation, and 3) monitoring of strategic plan outcomes and LCME compliance. The monitoring of the strategic plan outcomes and subset of LCME elements will ensure compliance with LCME accreditation standards, provide evidence regarding the impact of the strategic plan, and provide data that will be used to inform subsequent strategic planning and quality improvement efforts. The purpose of this policy is to outline the process for implementing the strategic plan, monitoring quality, and using data collected in the monitoring phase to develop future iterations of the strategic plan.


UNR Med will maintain and implement a strategic plan to guide quality improvement efforts. The implementation of the plan, as well as compliance with a subset of LCME standards will be systematically monitored. The strategic plan will be revised, based on data collected through the monitoring, no less frequently than every 3 years.

Responsibilities & Procedures

I. Responsibilities

A. The Office of Continuous Institutional Assessment (CIA) will:

Oversee the strategic planning process; develop, implement, and revise the CQI monitoring plan; and disseminate results.

II. Procedures

A. Strategic Plan Development and Revision

UNR Med will revise its strategic plan no less frequently than every three years. The strategic plan will be revised through an inclusive, data-informed process facilitated by the CIA. The strategic plan will include strategic initiatives that are aligned with the school's mission for the purpose of advancing the school's continuous quality improvement as an integrated system. Each initiative will have goals with specified metrics and targets for measuring progress. Metrics may be either process metrics or outcome metrics. For each outcome metric, a target must be included that will either be a numeric value representing what the school is expected to achieve by the completion of the strategic plan, or an estimated date for completing the target. 

Strategic plan revisions must be informed by data collected through CQI monitoring (see below), as well as any other relevant data. These data will be shared with individuals involved in the revision of the strategic plan in order to facilitate the development of data-driven goals, metrics, and targets and to promote quality improvement and innovation.

B. Strategic Plan Implementation

In order to facilitate the implementation of the strategic plan, UNR Med will use the RACI Model, a model that clearly define roles and responsibilities for organizational change (for more information on the RACI model, go to For each strategic plan metric, the CIA will identify the individual who is responsible and accountable for implementation and the individual(s) who should be consulted and informed regarding implementation and outcomes.

C. 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

a. Selection of Metrics to be Monitored

The CIA will monitor all metrics identified in the strategic plan as well as a subset of LCME elements. The CIA will review all LCME elements to identify the subset of elements that will be monitored. 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: Metrics that are included in the school's strategic plan and are the focus of current quality improvement efforts. 
    • Supporting LCME Elements: These are elements that are not considered a priority for improvement at this time but are closely related to the strategic plan initiatives and are considered to be central to the mission of our school. These elements are monitored to detect indirect effects of the implementation of the strategic plan and to ensure ongoing compliance. In addition, the continuous monitoring of these elements will help inform decision making for the next iteration of the strategic plan.
    • Best Practices: The CIA will review the literature no less frequently than every three years to identify best practices for CQI and incorporate these best practices into the CQI plan. LCME Elements for which monitoring is considered a best practice in the literature will be included in the CQI plan.

b. 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:

    1. Metric
    2. LCME element number, if applicable
    3. Relationship to the strategic plan, if applicable
    4. Data source
    5. Frequency of data collection
    6. The individual or group responsible for data collection, analysis, and reporting
    7. The individual or group who will receive and act on the findings, including the person/people who are responsible, accountable, consulted, and informed as described above (RACI model).
    8. Target, if the metric is included in the strategic plan

c. Reporting Requirements

The CIA will complete an annual report to summarize the school's status on each element included in the CQI plan. At minimum, this report will be shared with members of the UNR Med Executive Committee, the Dean's Cabinet, Faculty Council, and the Department Chairs. In addition, data on each element will be shared with the individual or group who has been identified for each RACI role. If there are concerns with the quality and/or compliance, that individual or group will develop a plan for improvement.

d. Updating and Revising the CQI Plan

The CIA will revise the CQI monitoring plan no less frequently than every 3 years, corresponding to the revision of the strategic plan. The elements that are included will be updated based upon changes to the LCME's Standards and Elements, changes to the school's strategic plan, and the current literature. Revisions to the plan will be shared with the Deans and Directors Committee for approval.


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).

Strategic Initiative: A compelling statement about where an organization is going that succinctly conveys a sense of what that organization wants to achieve in the long term. Strategic intent answers the question: "What exactly are we trying to accomplish?" Strategic initiatives apply to a broad area and consist of multiple goals, metrics, and targets.

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

Process Metric: Metrics that are specific steps in a process.

Outcome Metric: Quantitative metrics that measure the impact of an initiative.

Target: An agreed upon result that should be achieved by the completion of the strategic plan. For outcome metrics, targets should be quantitative and represent what the school is expected to achieve by the completion of the strategic plan. For process metrics, the target should be the agreed upon completion date.

Responsible: The person who is responsible for performing the work. For each metric, one person must be identified who is responsible for the implementation.

Accountable: The person ultimately accountable for the work or decision being made. For each metric, one person must be identified who is accountable for the implementation.

Consulted: Individuals who should be consulted with prior to a decision being made and/or the task being completed. For each metric, there can be as many people consulted as needed.

Informed: Individuals who must be informed when a decision is made or work is completed, and who must receive the results of the monitoring. For each metric, there can be as many people informed as needed.

RACI Model: A tool used for identifying roles and responsibilities during an organizational change process.

Strategic Plan: An organizational activity, based on the institution's vision and mission, that identifies the institution's priorities over the next several years.