Continuous Quality Improvement Policy
Purpose and Scope
This policy, along with corresponding procedures and guidelines, provides a framework for continuous quality improvement (CQI) in the Medical Student Education Program. The CQI policy is guided by UWSOM Medical Student Education Program’s Strategic Plan, specifically Strategic Priority #4, which aims to “instill a continuous quality improvement culture throughout UWSOM’s medical student education program.” The CQI policy serves two main purposes: (1) directs the UWSOM Medical Student Education Program’s implementation of CQI priorities and processes associated with the outcomes of the strategic priorities; and (2) ensures systemic monitoring of the medical education program’s compliance with accreditation standards per LCME Element 1.1 Strategic Planning and Continuous Quality Improvement.
Policy Statement
The University of Washington School of Medicine engages in data-driven and systemic continuous quality improvement of its Medical Student Education Program to achieve two outcomes: (1) its mission, goals, and values in accordance with the Medical Student Program Strategic Plan; and (2) compliance with the Liaison Committee on Medical Education accreditation standards.
Procedures and Guidelines
The UWSOM’s Continuous Quality Improvement (CQI) Procedures and Guidelines specify the implementation plan for the CQI cycle. The key areas of the procedures and guidelines include the following:
- CQI Monitoring, Governance and Responsible Individuals
- CQI Criteria Pertaining to Accreditation, Definition, and Review Schedule
- Regular CQI communication
1. CQI Monitoring Governance and Responsible Individuals
At UWSOM, the Educational Quality Improvement (EQI) Office is responsible for developing, implementing, and monitoring data-driven CQI interventions for improving the Medical Student Education Program. It also serves as an administrative arm to the Educational Quality Improvement Strategic Planning (EQISP) Committee, which oversees the UWSOM Medical Student Education Program Strategic Plan.
The EQI Office reports to the Vice Dean for Academic, Rural, and Regional Affair. Led by Associate Dean of EQI, the EQI office fulfills the following responsibilities:
- Conduct systematic CQI by:
- Collecting, reviewing, analyzing data, and disseminating data reports to medical school stakeholders
- Alerting responsible individuals across academic and regional affairs regarding CQI priority needs and jointly planning, executing, and monitoring CQI initiatives within their domain of responsibility.
- Monitoring progress of CQI interventions based on student survey ratings and narrative comments.
- Supporting the EQISP Committee’s strategic plan priorities including monitoring outcomes associated with strategic priorities.
- As a CQI clearinghouse, serve as resource for CQI planning and monitoring as well as communicating to all stakeholders evolving accreditation standards that affect CQI.
2. CQI Criteria Pertaining to Accreditation Definition, and Review Schedule
The table below categorizes the LCME elements based on their citation risk and respective review schedules.
3. Regular CQI Communication
The EQI Office is responsible for presenting key CQI datasets with recommendations for improvement to the following stakeholders:
- Key committees in the medical schools including the following: Medical School Executive Committee, Educational Quality Improvement Strategic Plan Committee, Curriculum Committee, Foundations Phase Committee, Patient Care Committee, Explore & Focus Phase Committee, and Learning Environment Committee
- Academic, Rural and Regional Affairs leaders including foundations deans, clinical deans, staffs
- The student community through the distribution of survey data reports.
- Bi-monthly CQI Spotlight series published in student newsletters, featuring priority CQI activities in the medical student education program.
Definitions
Liaison Committee on Medical Education (LCME) – the accreditation granting body of the Association of American Medical Colleges with authority over all allopathic medical schools in the United States and Canada.
Association of American Medical Colleges (AAMC) – the non-profit organization representing all medical allopathic medical schools in the United States and Canada. The AAMC also represents teaching hospitals, health systems and academic societies.
Continuous Quality Improvement (CQI) – the method 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) – the template of questions, prompts, tables and supplemental requests that the Liaison Committee on Medical Education (LCME) provides medical schools in order to evaluation their medical education program in the accreditation process.
Responsible Individuals – the individuals designated with the responsibility to directly initiate, manage, oversee and report on continuous quality improvement interventions and activities.
A List of Data for CQI Process
The list of data used for CQI consists of, but not limited to, the following:
- End-of-Phase Survey (EOP) – the survey tool administered at the end of Foundations, Patient Care and Explore and Focus phases.
- Graduate Questionnaire (GQ) – the survey administered to graduating medical students by the Association of American Medical Colleges (AAMC).
- Year-Two Questionnaire (Y2Q) – the survey administered to second year medical students by the Association of American Medical Colleges (AAMC).
- Student Performance Data:
- NBME STEP 1
- NBME STEP 2
- Block Exams/Grades
- Clerkship Exams/Grades
- Student Feedback Data:
- End-of-Block Evaluation
- End-of-Clerkship Evaluation
Procedures, Guidelines and Requirements & Date Adopted (if appropriate):
Adopted by EQISP Committee on March 24, 2019
Revised Approved on September 6, 2019
Reviewed by EQISPC on September 5, 2024
Revision Approved on September 23, 2024
Revision Approved by FCAA on October 8, 2024
Policy Contact: Educational Quality Improvement Office. eqi@uw.edu