Continuous Quality Improvement Initiative

Purpose

The Continuous Quality Improvement (CQI) Initiative ensures that the University of Minnesota Medical School conducts systematic evaluation of its educational program to promote efficiency, effectiveness and ongoing improvement.
Monitoring of the educational program is expected to occur regularly. Areas of monitoring that form the basis for continuous quality improvement (CQI) efforts include, but are not limited to:

  • New Liaison Committee for Medical Education (LCME) expectations or requirements.
  • Standards or Elements cited in prior LCME reports as requiring monitoring or are/have been in non-compliance, especially those requiring the submission of Status Reports.
  • Institutional objectives and/or strategic plans that may affect the educational program, services, or resources.
  • Undergraduate medical education (UME) strategic objectives.

CQI fosters an environment where the medical school is engaging in a continuous and intentional process aimed at supporting educational program improvement, contributes to positive outcomes during accreditation review, and meets the LCME accreditation requirement as follows:

Element 1.1: Strategic Planning and Continuous Quality Improvement
”A medical school engages in ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goals, result in the achievement of measurable outcomes used to improve programmatic quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards.”

Procedures

A key part of the Initiative is the maintenance of a Continuous Quality Improvement Committee charged with monitoring compliance with the Liaison Committee on Medical Education (LCME) accreditation standards and elements. The Committee will identify both long- and short-term goals, implement a systematic process to collect and review data, and disseminate outcomes to appropriate leadership and administration, The Committee will also collaborate with leadership and administration to identify Quality Improvement Plans (QIP) to achieve goals, as evidenced by measurable outcomes.


CQI Committee Core Membership

  • Robert Englander, MD, MPH, Associate Dean for Undergraduate Medical Education – Chair
  • Joseph Oppedisano, DAc, Director of Accreditation, Compliance, And Quality Improvement – Co-Chair
  • Mark Rosenberg, MD, Vice Dean for Medical Education & Academic Affairs
  • Emily Melcher, AHC Information Systems Manager
  • Ali Niesen, Special Projects Manager
  • Austin Calhoun, PhD, Medical Education Chief of Staff
  • Robin Michaels, PhD, Associate Dean for Student Life & Academic Affairs
  • Two student representatives, recommended by Student Council and appointed by the Dean

Remaining members are selected via an invitation from the Co-Chairs of the Committee. External recommendations for membership may be made with final authority for membership resting with the Co-Chairs.

The overall makeup of the CQI Committee is intended to be flexible in order to respond effectively to the needs of the medical school. As such, the size of the Committee (including a sub-set constituting a Working Group), specific representation, and tenure are not prescriptive.

Additional ad hoc members (e.g. Finance, Human Resources, Facilities, etc.) can be engaged as part of a Working Group or in Quality Improvement Plans on an as-needed basis.

The CQI Committee membership is reviewed and approved by the Dean, on an annual basis.

CQI Committee Duties & Responsibilities

  • 1Identify and prioritize accreditation elements to be reviewed and monitored on an annual basis. Reasons for monitoring may include, but are not limited to, national trends, elements cited in previous full surveys, identified areas of needed improvement, etc.
  • Share outcomes and recommendations to leadership and administration. Collaborate and coordinate efforts to develop, achieve, and maintain goals and limit slippage.

CQI Working Group Duties & Responsibilities

  • Oversee the development of a data collection and management system.
  • Maintain a system of monitoring elements, which includes a formal review process entailing the development of recommendations, timelines, and goals.
  • Review and ensure policies and processes are systematically monitored and updated as needed and deemed appropriate.

Meetings

The larger CQI Committee should, ideally, meet once per semester to monitor the overall effectiveness of the Committee, recommend changes to membership, evaluate new and/or ongoing priorities and review prior accomplishments.

A Working Group, constituting a sub-set of the Committee with additional membership comprising key stakeholders, as needed, should meet monthly in order to monitor compliance with LCME Standards/Elements, determine progress on outstanding QIPs, update any established monitoring systems (e.g. Dashboards), and determine steps for initiating new QIPs.

Organization

The CQI Committee functions in an advisory and collaborative role with leadership and administration. The goal of the Committee is not to mandate specific departmental or programmatic functions or activities. The Committee (and its Working Group) provides ongoing assessment of aspects of the educational program in light of accreditation requirements, determines if there are areas of slippage, and identifies opportunities for improvement. Implementation of any recommendations resulting from a QIP rests with appropriate oversight individuals within a given department or program. The outcome of such recommendations will, however, be noted by the Committee for purposes of data gathering and/or future CQI efforts.

During Preparations for an LCME site review and self-study, members of the CQI Committee are expected to also serve on the LCME Executive Task Force.