Continuous Quality Improvement Initiative

Continuous Quality Improvement (CQI) fosters an environment where the medical school engages in a continuous and intentional process aimed at supporting educational program improvement, contributing to positive outcomes during accreditation review, and meeting the Liaison for Medical Education (LCME) accreditation requirement:

Element 1.1: Strategic Planning and Continous 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."

Areas of monitoring that form the basis for continuous quality improvement (CQI) efforts include:

    • Identification of risk areas based on current LCME Standards and Elements
    • Ongoing citations of Standards or Elements from previous accreditation visit
    • Institutional strategic planning objectives that impact the medical education program, services, or resources in such instances where they overlap or align with accreditation standards

A key part of CQI is the maintenance of individuals and groups with responsibility for evaluating and improving components of the medical education program as a whole, especially those associated with ensuring the UMMS meets LCME requirements. While not exhaustive, brief descriptions of the key groups and individuals are provided below.

  • Vice Dean for Education & Academic Affairs: Continuous Quality Improvement efforts related to the educational mission of the school and associated with compliance with LCME requirements, are the responsibility of the Office of Medical Education (OME) under the purview of the Vice Dean for Education and Academic Affairs. Priorities for CQI efforts as they relate to this policy will focus on areas that have direct impacts on undergraduate medical education and the undergraduate medical student experience.

  • Medical Student Education Committee (MSEC): The MSEC and its subcommittees are charged with full and absolute responsibility for thecontinuous quality improvement (CQI) processes in the design, review, evaluation, and policies associated with the curricular program as a whole. This includes curricular content, methods of pedagogy and assessment, and setting standards of achievement for successful graduation from the medical education program. 

  • Office of Accreditation and Continuous Quality Improvement (OACQI): Under the Director, The Office: 1) provides overall direction in establishing systems for ongoing monitoring of LCME compliance; 2) serves as liaison to the LCME regarding accreditation-related questions; 3) supports the CQI Steering Committee and the Vice Dean for Education & Academic Affairs in accreditation-related efforts; 4) collaborates with the MSEC and with other offices of the medical school to advise on LCME requirements and maintain compliance in their charges; 5) develop and implement CQI initiatives as part of an overall quality management system; 6) coordinate all administrative tasks associated with accreditation Self-Study periods.

  • CQI Steering Committee: Chaired by the Vice Dean for Education & Academic Affairs, the CQI Steering Committee has oversight in monitoring compliance with LCME Standards, setting accreditation-related priorities, obtaining progress reports from relevant stakeholders on compliance with, or improvement plans related to, LCME Standards and Elements. Intentionally flexible, membership to the CQI Steering Committee should reflect a broad range of stakeholders across all aspects of the educational program. It is also expected that members will serve on the LCME Executive Task Force during Institutional Self-Study periods, whenever possible. The CQI Steering Committee should provide updates to the Dean and the Dean’s Leadership Team, at a minimum annually.

For more information about the LCME, visit  

For questions about CQI Initiatives, contact Joseph Oppedisano, DAc, Director of Accreditation and Quality Improvement at