Policy on Continuous Quality Improvement (CQI)

The Zucker School of Medicine engages in ongoing planning and continuous quality improvement processes that (1) establish short- and long-term programmatic goals, (2) result in the achievement of measurable outcomes that are used to improve programmatic quality, and (3) ensure effective monitoring of the medical education program's compliance with accreditation standards. The CQI process is overseen by the Office of the Dean.   

CQI responsibilities under the oversight of the senior associate dean for education:

  • Development of criteria for including an element in the CQI plan
  • Identification of LCME elements to be monitored
  • Identification of measures of compliance and source of data
  • Delineation of responsible and accountable parties
  • Determination of frequency of monitoring 
  • Establishment of benchmarks
  • Identification of metrics to determine compliance 
  • Management of  the CQI calendar to ensure timely collection, analysis, and dissemination of data
  • Preparation of annual status report for the Dean and leadership team

LCME elements for monitoring and/or improvement in the CQI plan are identified from the following categories:

  • Elements that include an explicit requirement for monitoring or involve a regularly occurring process
  • New or recently-revised or changes in LCME expectations related to performance in elements
  • Elements that could be reviewed to ensure that policies are congruent with current operations
  • Elements that directly or indirectly affect the core operations of the school
  • Elements that were cited in the medical school's previous accreditation surveys
  • Elements that were commonly cited in the last three years
  • Other elements that were identified through program evaluation processes, the Curriculum Committee, or via School of Medicine leadership

Click here for the complete list of elements that are monitored.

The CQI process is based on the premise that a content expert ("owner") is responsible for portions of the educational program. Owners are responsible for executing an analysis for areas that have been identified as in need of improvement. During the analysis, owners work with various stakeholders to develop and implement any necessary adjustments. Data is collected to monitor the success of the plan, and at an agreed-upon interval, the owners will provide a status report to the associate dean for curricular integration and assessment.  

References to Regulations and/or Other Related Policies:
LCME Element 1.1: Strategic Planning and Continuous Quality Improvement