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:
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Monitoring each LCME element on a defined cycle (e.g., annually, biennially, or triennially), based on risk and institutional priorities.
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Collecting and reviewing data from relevant stakeholders, institutional databases, and academic units.
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Identifying areas for improvement or potential non-compliance.
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Developing and tracking action plans to address issues.
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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, MD Ms. Hope Terhaar, MA Dr. Anderson Spickard, MD
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 |
Contact Us
Thomas F. Frist, Jr. College of Medicine
1900 Belmont Boulevard
Nashville, TN 37212
Phone: 615.460.6191