Continuous Quality Improvement Initiative

CQI Policy


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:

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

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.”


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 Duties & Responsibilities

The CQI Steering Committee will identify and establish priorities for CQI efforts at the medical school that directly impact undergraduate medical education and are founded on accreditation standards. Examples of such efforts may include comprehensive reviews of LCME Standards or Elements and reviewing the status of action plans resulting from LCME citations in preparation for the submission of Status Reports.

CQI Committee Core Membership

Membership to the CQI Steering Committee should reflect a broad range of stakeholders across all aspects of the educational program (OME, Undergraduate Medical Education, Graduate Medical Education, affiliate hospitals, departments, Faculty Affairs, students, campuses, and others as needed). However, the makeup of the Steering Committee is intentionally flexible in order to respond effectively to the needs of the medical school. The Steering Committee will be comprised of 7-12 members. It is also expected that appropriate members who serve on the CQI Steering Committee will also serve as members of the LCME Executive Task Force during the Self-Study period, whenever possible. Membership shall be reviewed annually and final decisions regarding membership will be approved by the Vice Dean for Medical Education and Academic Affairs.

The Vice Dean for Medical Education and Academic Affairs shall serve as Chair of the Steering Committee. At minimum, membership should consider stakeholders from the following areas:

  • Administrative leadership from Faculty Affairs, GME, Admissions, and OME in general
  • Representatives from teh Regional Campus in Duluth
  • Medical Students
  • Residents
  • Representatives of affiliate hospitals
  • Departmental representatives (e.g. Department Chairs)
  • Faculty representation with preclinical and clinical teaching/educational roles


CQI Working Group Duties & Responsibilities

The CQI Steering Committee charges a CQI Working Group, led by the Director of Accreditation, Compliance and Continuous Quality Improvement, with assembling a group of operational leaders who will be responsible for:

  • Reviewing performance on LCME Standards or Elements within a given Standard
  • Regularly monitoring components of the Data Collection Instrument
  • Annually reviewing policies associated with Accreditation Standards and Elements
  • Developing CQI Dashboards
  • Providing support to departments or programs where a CQI recommendation has been made
  • Developing and implementing Quality Improvement Plans (QIP)


Quality Improvement Plans:

The CQI Steering Committee will determine priorities. Prioritization should be founded in the context of the available data including, but not limited to, the most recent version of the Data Collection Instrument (DCI), previous accreditation reports, LCME Status Reports, AAMC Graduation & Year Two Questionnaires, Independent Student Analyses, Executive Summaries, and internally generated data. In addition, the Working Group may conduct needs assessments for those QIPs that involve an office or program that inform the Steering Committee’s evaluations.

Based on identified priorities the Working Group will initiate QIPs outlining, at minimum:

  • The purpose and scope of the project
  • Quantifiable goals and outcome measures
  • Responsible individuals
  • Description of how the effectiveness of the QIP will be measured

Results from QIPs will be assigned to the appropriate process owners and monitored by the CQI Steering Committee on a regular basis.



CQI Steering Committee: Steering Committee meetings should occur, at a minimum, twice a year in order to review the status of QIPs, review progress from the Working Group, prepare for any Status Reports required by the LCME on outstanding citations, and to establish its priorities for the upcoming year.

CQI Working Group: The Working Group should, ideally, meet monthly to provide updates on current QIPs, review any new requests, determine next steps in current action plans. Additionally, the Working Group may provide regular updates to the CQI Steering Committee, Education Council, and other stakeholders on a regular basis or as needed.



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.