College of MedicineCollege of MedicineAboutCollege of Medicine PoliciesContinuous Quality Improvement

Continuous Quality Improvement Policy 

Policy Number: EC.13.01.240903

Applies to: Washington State University’s Elson S. Floyd College of Medicine administration, faculty, and staff.

Date: 09/03/2024

1.0 Policy Statement

Washington State University’s Elson S. Floyd College of Medicine (COM) will engage in deliberate planning to continuously improve the quality of the medical college to promote and maintain a continuous culture of excellence in meeting program goals and standards. As such, this policy establishes that:

  • 1.1 The COM will engage in continuous quality improvement as part of its strategic planning and daily operations to ensure effective monitoring of measurable outcomes and to achieve short and long-term programmatic goals.
  • 1.2 The COM will maintain a CQI Committee to promote and oversee a culture of continuous quality improvement and act in an advisory and collaborative role with leadership and administration to oversee the continuous improvement of the medical college and compliance with all accreditation standards (LCME, ACGME, etc.).
  • 1.3 The COM will maintain institutional standards of compliance with and quality benchmarks for accreditation standards and requirements.
  • 1.4 The COM will maintain a monitoring schedule for all accreditation standards to analyze collected data, to identify significant trends and develop comprehensive recommendations aimed at enhancing programmatic and operational effectiveness.
  • 1.5 The COM will maintain a unified and collaborative framework for continuous quality improvement initiatives across the organization.

2.0 Definitions

Accreditation Council for Graduate Medical Education (ACGME)

The not-for-profit organization that sets and monitors voluntary professional educational standards in preparing physicians to deliver safe, high-quality medical care and oversees the accreditation of residency and fellowship programs in the US.

Association of American Medical Colleges (AAMC)

The non-profit organization representing medical schools, teaching hospitals, and academic and scientific societies. The AAMC co-sponsors the Liaison Committee on Medical Education.

Continuous Quality Improvement (CQI)

The continual process of monitoring and improving the quality of the college of medicine. The CQI process provides a deliberate, reliable framework for promoting quality improvement, evaluating operational effectiveness, identifying measurable improvements, implementing improvement action plans, monitoring changes for effectiveness, and ensuring best practices are replicated.

Liaison Committee on Medical Education (LCME)

The accrediting body for all U.S. MD-granting medical education program. The American Medical Association and Association of American Medical Colleges are co-sponsors of the LCME.

Plan, Do, Study, Act (PDSA)

A methodology for continuous evaluation of operational processes to drive short-term and long-term quality improvement of an organization.

3.0 Responsibilities

Office of Strategic Management

4.0 Procedures

CQI Approach

The college will establish and maintain institutional standards that define the minimum acceptable quality level for all educational programs. These standards will form the basis for gauging how well the college’s educational programs are meeting the expectations for accreditation and our communities’ health care needs. The approach includes:

  • Implementing an effective CQI methodology (e.g., PDSA, Six Sigma, etc.)
  • Understanding accreditation requirements and expectations.
  • Defining institutional standards of compliance and key performance indicators to ensure compliance with accreditation requirements.
  • Committing to the continuous monitoring of educational programs
  • Evaluating quality and performance.
  • Identifying opportunities for improving quality and creating action plans to systematically achieve planned improvements.
  • Institutionalizing improvements to sustain improved quality.

CQI Committee

The CQI Committee will promote innovation and a continuous improvement culture throughout the medical college’s programs, teams, and processes to support strategic goals. The committee will be structured to sustain accreditation compliance and achieve ongoing quality improvement, with members representing key stakeholders across the college. Specific roles and membership will be outlined in the CQI committee’s bylaws. The committee will review and assess all quality aspects of the college’s programs to ensure compliance with accreditation standards, identify areas for improvement, recommend and oversee interventions that address quality concerns, and facilitate the sharing of best practices and lessons learned across the COM.

The CQI Committee will oversee the college’s CQI activities to include monitoring of general accreditation requirements and the effectiveness of improvement interventions. The CQI Committee will collaborate with the educational programs and operational offices to develop specific monitoring plans to meet each program’s respective accreditation requirements.

LCME Accreditation Element Monitoring

The CQI Committee, in collaboration with educational programs and operational offices, will identify the monitoring periodicity of each LCME accreditation element and maintain a consolidated monitoring schedule. In general, the rational for monitoring elements will be based on the frequency of changes or availability of data to measure performance of outcomes associated with the elements’ focus area. In general, all elements will be monitored and assessed annually to determine compliance. Elements meeting the criteria below will require more frequent monitoring to ensure compliance.

  • Elements determined by Dean’s Cabinet, UMEC, or CQI Committee to be high risk or not in compliance.
  • Elements that directly or indirectly affect the core operation of the college.
  • Elements with outcomes that indicate a trend that may result in a deviation from the LCME expectations or college’s standards.
  • Elements that include language that monitoring is required or involves a regularly occurring process that may be prone to slippage.
  • Elements cited as unsatisfactory or satisfactory with monitoring during previous site visits.
  • Elements with compliance/satisfactory rating change since previous site visits.
  • New elements or elements where the LCME has made substantial changes.
  • Elements that are the focus of quality improvement efforts.
  • Elements that include policies that must be congruent with operations and affected by changes to policies, procedures, or workflows.
  • Elements for which outcomes are collected as part of a regularly occurring processes (e.g., grade submissions, duty hours, mistreatment reports, and student well-being).
  • Elements that rely on evaluation and national survey data (e.g., internal questionnaires, student feedback surveys, and AAMC Questionnaires) as a metric for informing compliance with college or LCME standards.

5.0 Related Policies

N/A

6.0 Key Search Words

Continuous Quality Improvement, CQI Committee, Accreditation, Element Monitoring

7.0 Revision History

Original Approval: 09/03/2024
Policy Number: EC.13.01.240903
Review/Revision: 09/03/2024