College of Medicine staff talk and networking during the College of Medicine staff meeting

Continuous Quality Improvement

Thomas F. Frist, Jr. College of Medicine

The LCME-required Continuous Quality Improvement (CQI) Monitoring Cycle is a systematic process used by medical schools to regularly assess, document, and improve compliance with LCME accreditation standards. It ensures that the institution maintains accreditation readiness between formal site visits by:

  • Monitoring each LCME element on a defined cycle (e.g., annually, biennially, or triennially), based on risk and institutional priorities.

  • Collecting and reviewing data from relevant stakeholders, institutional databases, and academic units.

  • Identifying areas for improvement or potential non-compliance.

  • Developing and tracking action plans to address issues.

  • Reporting progress to the school’s leadership and CQI task force.

This cycle promotes a culture of continuous improvement and helps ensure that the medical education program remains aligned with accreditation expectations and institutional goals.

Continuous Quality Improvement (CQI)

Our CQI monitoring process ensures ongoing compliance with LCME standards through structured review cycles (annual, biennial, triennial), tracking of newly revised elements, previously cited items, and issues flagged through CQI referrals. All LCME elements are managed through a centralized dashboard overseen by the Director of Accreditation and CQI.

Workplans are reviewed quarterly and must include data sources, action dates, review timelines, and responsible individuals. The CQI Task Force meets monthly to address submitted issue forms, review workplans (with contributors presenting their plans), and develop quarterly reports for leadership. Committee decisions are documented and linked to specific LCME elements to support comprehensive oversight and continuous improvement.

The FCoM Continuous Quality Improvement (CQI) Task Force is a dedicated team that meets monthly to guide and support quality improvement efforts. Members include the Dean, Associate Dean of Medical Education, Director of Accreditation and CQI, one student representative, and two additional members appointed by the Dean.

The Task Force establishes monitoring cycles, assigns and reviews CQI workplans, analyzes outcome data, and produces regular CQI reports. The Director of Accreditation and CQI leads the overall process, maintains internal communication platforms for faculty and staff, and manages the public accreditation website. The Dean ensures CQI policy is implemented, while the Associate Dean of Medical Education oversees adherence.

CQI Task Force Members

Dr. Ruth Stewart              hope-terhaar.jpg           anderson-spickard.jpeg

Dr. Ruth Stewart, MD                    Ms. Hope Terhaar, MA          Dr. Anderson Spickard, MD

john-muise.jpg             pat-whitworth.jpg       Haley Rague

 Mr. John Muise, MA                       Dr. Pat Whitworth, MD           Haley Rague, MS2

Element Monitored

Timing of Monitoring

Monitored By

1 Mission, Planning, Organization and Integrity

Annually

Dean, School of Medicine; Provost

1.1 Strategic Planning and CQI

Annually

Dean, School of Medicine; Provost

1.2 Conflict of Interest (COI) Policies

Every 2 Years

Associate Dean for Faculty Success

 

1.3 Mechanisms for Faculty Participation

Annually

Dean, School of Medicine; Provost

1.4 Affiliation Agreements

Annually

Dean, School of Medicine; Provost

1.5 Bylaws

Annually

Dean, School of Medicine; Provost; University Counsel at Belmont

1.6 Eligibility Requirements

Every 3 Years

Reviewed for Quality Assurance Only

Element Monitored

Timing of Monitoring

Monitored By

2.1 Administrative Officer and Faculty Appointments

Every 2 Years

Reviewed for Quality Assurance Only

2.2 Dean’s Qualifications

Every 2 Years

Reviewed for Quality Assurance Only

2.3 Access and Authority of the Dean

Every 2 Years

Reviewed for Quality Assurance Only

2.4 Sufficiency of Administrative Staff

Annually

Dean, School of Medicine; Provost

Element Monitored

Timing of Monitoring

Monitored By

 3.1 Resident Participation

Annually

Associate Dean of Medical Education

3.2 Community of Scholars/ Research

Every 2 Years

Dean, School of Medicine; Provost

3.4 Anti-Discrimination Policy

Every 2 Years

Review for Quality Assurance

3.5 Learning Environment/ Professionalism

Annually

Dean, School of Medicine; Provost

3.6 Student Mistreatment

Annually

Dean, School of Medicine; Provost

Element Monitored

Timing of Monitoring

Monitored By

4.1 Sufficiency of Faculty

Annually

Dean, School of Medicine; Provost

4.2 Faculty Appointment Policies

Annually

Review for Quality Assurance

4.3 Scholarly Productivity

Annually

Dean, School of Medicine; Provost

4.4 Feedback to Faculty

Annually

Office of Faculty Success, Office of Foundational and Clinical Sciences, CQI Task Force

4.5 Faculty Professional Development

Annually

Dean, School of Medicine; Provost

4.6 Responsibility for Medical School Policies

Annually

Office of Medical Education; Office of Foundational and Clinical Sciences; Office of Faculty Success; Office of Student Affairs and Belonging; CQI Task Force

Element Monitored

Timing of Monitoring

Monitored By

5.0 Educational Resources and Infrastructure

Annually

Dean, School of Medicine; EVP for Financial Excellence

5.1 Adequacy of Financial Resources

Annually

Dean, School of Medicine; EVP for Financial Excellence

5.2 Dean’s Authority/ Resources

Every 2 Years

Dean, School of Medicine; Provost

5.3 Pressures for Self-Financing

Every 2 Years

Dean, School of Medicine; Provost

5.4 Sufficiency of Buildings and Equipment

Annually

Dean, School of Medicine; Provost

5.5 Resources for Clinical Instruction

Annually

Associate Dean of Medical Education

5.6 Clinical Instructional Facilities

Annually

Dean, School of Medicine; Provost; Chair of Foundational and Clinical Department; Associate Dean of Medical Education

5.7 Security, Student Safety, and Disaster Preparedness

Annually

Office of General Counsel

5.8 Library Resources

Every 2 Years

Associate Dean of Medical Education; FCoM Librarian

5.9 Information Technology Resources/ Staff

Every 2 Years

Associate Dean of Medical Education

5.10 Resources Used by Transfer/Visiting Students

Every 2 Years

Associate Dean of Medical Education

5.11 Study/Lounge/Storage Space/Call Rooms

Every 2 Years

Dean, School of Medicine; Associate Dean of Medical Education: Provost

5.12 Required Notifications to the LCME

Annually

Review for Quality Assurance

Element Monitored

Timing of Monitoring

Monitored By

6 Competencies, Curricular Objectives, and Curricular Design

Annually

Associate Dean of Medical Education

6.1 Program & Learning Objectives

Annually

Associate Dean of Medical Education

6.2 Required Clinical Experiences

Annually

Associate Dean of Medical Education

6.3 Self-Directed & Life-Long Learning

Annually

Associate Dean of Medical Education

6.4 Inpatient/Outpatient Experiences

Annually

Associate Dean of Medical Education

6.5 Elective Opportunities

Annually

Associate Dean of Medical Education

6.6 Service-Learning/Community Service

Annually

Associate Dean of Medical Education; Associate Dean of Student Affairs and Belonging

6.7 Academic Environments

Annually

Review for Quality Assurance

6.8 Education Program Duration

Annually

Associate Dean of Medical Education

Element Monitored

Timing of Monitoring

Monitored By

7.1 Biomedical, Behavioral, Social Sciences

Every 2 Years

Associate Dean of Medical Education

7.2 Organ Systems/Life Cycle/Prevention/Symptoms/Signs/Diff Diagnosis, Tx Planning

Every 2 Years

Associate Dean of Medical Education

7.3 Scientific Method/ Clinical/ Translational Research

Every 2 Years

Associate Dean of Medical Education

7.4 Critical Judgment/Problem-Solving Skills

Every 2 Years

Associate Dean of Medical Education

7.5 Societal Problems

Every 2 Years

Associate Dean of Medical Education

7.6 Cultural Competence and Health Care Disparities

Every 2 Years

Associate Dean of Medical Education

7.7 Medical Ethics

Every 2 Years

Associate Dean of Medical Education

7.8 Communication Skills

Every 2 Years

Associate Dean of Medical Education

7.9 Inter-professional Collaborative Skills

Every 2 Years

Associate Dean of Medical Education

Element Monitored

Timing of Monitoring

Monitored By

8.0 Curricular Management, Evaluation, and Enhancement

Annually

Associate Dean of Medical Education

8.1 Curricular Management

Annually

Associate Dean of Medical Education

8.2 Use of Medical Educational Program Objectives

Annually

Associate Dean of Medical Education

8.3 Curricular Design, Review, Revision

Annually

Associate Dean of Medical Education

8.4 Evaluation of Educational Program Outcomes

Annually

Dean, School of Medicine; Associate Dean of Medical Education; Department Chairs; Provost

8.5 Medical Student Feedback

Annually

Associate Dean of Medical Education

8.6 Monitoring of Completion of Required Clinical Experiences

Annually

Associate Dean of Medical Education

8.7 Comparability of Education/ Assessment

Annually

Associate Dean of Medical Education

8.8 Monitoring Student Time

Annually

Associate Dean of Medical Education

Element Monitored

Timing of Monitoring

Monitored By

9.1 Preparation of Resident and Non-Faculty Instructors

Annually

Office of Faculty Success; CQI Task Force

9.0 Teaching, Supervision, Assessment, and Student and Patient Safety

Annually

Associate Dean of Medical Education

9.1 Preparation of Resident and Non-Faculty Instructors

Annually

Dean, School of Medicine; Curriculum Committee

9.2 Faculty Appointments

Annually

Associate Dean of Medical Education

9.3 Clinical Supervision of Medical Students

Annually

Associate Dean of Medical Education

9.4 Assessment System

Annually

Associate Dean of Medical Education

9.5 Narrative Assessment

Annually

Associate Dean of Medical Education

9.6 Setting Standards Of Achievement

Annually

Associate Dean of Medical Education

9.7 Formative Assessment & Feedback

Annually

Associate Dean of Medical Education

9.8 Fair & Timely Summative Assessment

Annually

Associate Dean of Medical Education

9.9 Student Advancement & Appeal Process

Annually

Associate Dean of Medical Education

Element Monitored

Timing of Monitoring

Monitored By

10.0 Medical Student Selection, Assignment, and Progress

Annually

Associate Dean of Admissions

10.1 Premedical Education/Required Coursework

Every 2 Years

Associate Dean of Admissions

10.2 Final Authority of Admission Committee

Every 2 Years

Associate Dean of Admissions

10.3 Policies Regarding Student Selection/Progress and Their Dissemination

Every 2 Years

Associate Dean of Admissions

10.4 Characteristics of Accepted Applicants

Every 2 Years

Associate Dean of Admissions

10.5 Technical Standards

Annually

Dean, School of Medicine

10.6 Content of Informational Materials

Every 2 Years

Associate Dean of Admissions

10.7 Transfer Students

Every 2 Years

Associate Dean of Admissions

10.8 Visiting Students

Every 2 Years

Associate Dean of Admissions

10.9 Student Assignment

Every 2 Years

Associate Dean of Medical Education

Element Monitored

Timing of Monitoring

Monitored By

11.0 Medical Student Academic Support, Career Advising, and Educational Record 

Annually

Associate Dean of Student Affairs and Belonging

11.1 Academic Advising and Academic Counseling

Annually

Associate Dean of Student Affairs and Belonging

11.2 Career Advising

Annually

Associate Dean of Student Affairs and Belonging

11.3 Oversight of Extramural Electives

Annually

Associate Dean of Student Affairs and Belonging

11.4 Provision of MSPE

Annually

Review for Quality Assurance

11.5 Confidentiality of Student Educational Records

Every 2 Years

Review for Quality Assurance

11.6 Student Access to Educational Records

Every 2 Years

Review for Quality Assurance

Element Monitored

Timing of Monitoring

Monitored By

12.0 Medical Student Health Services, Personal Counseling, and Financial Aid Services

Annually

Office of Student Affairs and Belonging

12.1 Financial Aid/Debt Mgmt. Counseling

Annually

Office of Student Affairs and Belonging

12.2 Tuition Refund Policy

Every 2 Years

Review for Quality Assurance

12.3 Personal Counseling/ Mental Health/ Well-Being

Annually

Associate Dean of Student Affairs and Belonging; Office of Student Services

12.4 Student Access to Health Care Services

Annually

Associate Dean of Medical Education; Associate Dean of Student Affairs and Belonging

12.5 Non-Involvement of Providers of Health Services in Student Assessment/ Location of Student Health Records

Every 2 Years

Associate Dean of Medical Education

12.6 Student Health and Disability Insurance

Annually

Review for Quality Assurance

12.7 Immunization Requirements and Monitoring

Every 2 Years

Associate Dean of Student Affairs and Belonging

12.8 Student Exposure Policies/ Procedures

Every 2 Years

Office of Environmental Safety; Office of Student Affairs and Belonging