The Office of Accreditation and Quality Improvement (OAQI) will determine which elements of the Jacobs School will be monitored based on internal assessments and the LCME 2016 publication Implementing a System for Monitoring Performance in LCME Accreditation Standards.
1.1a Elements that include language that monitoring is required or involve a regularly-occurring process that may be prone to slippage. (Updated annually at the AAMC meeting)
1.1b Elements for which the Jacobs School has been cited in the past (Results of the most recent accreditation site visit)
1.1c Elements Commonly cited by the LCME (as listed in LCME Publications)
1.1d New LCME elements or elements where LCME expectations have evolved (Collected from most recent version of LCME publications Functions and Structure of a Medical School and Data Collection Instrument for Full Accreditation Surveys)
1.1e Elements that include policies that must be congruent with current operations. (Collected from most recent version of LCME publications Functions and Structure of a Medical School and Data Collection Instrument for Full Accreditation Surveys)
1.1f Elements that directly or indirectly affect the core operations of the school. (Collected from most recent version of LCME publications Functions and Structure of a Medical School and Data Collection Instrument for Full Accreditation Surveys)
1.1g LCME standards/elements that monitor and assess achievement of the current Jacobs School Strategic Plans
1.1h Elements/Standards for which a need for extra scrutiny has been identified during the MAC Review or self-study period prior to an accreditation visit.
1.1i Elements/Standards recommended by the Dean, which are related to new policies, strategic plans, or processes at the Jacobs School.
1.1j Elements/Standards for which the Jacobs School performance on the AAMC GQ has fallen below national average or shows a downward trend.
The OAQI will prioritize elements and standards as appropriate, with the goal to progress to regular monitoring of all elements and standards contained within the DCI in the future.
Priority will be given as follows:
1.2a High Priority will be given to elements/standards listed in 1.1b (Previous Citations of the Jacobs School), until such element/standards are deemed to be compliant by the LCME at the next full accreditation site visit.
1.2b High Priority will be given to elements/standards listed in 1.1h, for which the OAQI has determined non-compliance during a MAC Review or the Self-Study period leading up to an upcoming accreditation site visit.
1.2c High Priority will be given to elements/standards listed in 1.1d (New LCME elements or elements where LCME expectations have evolved), until compliance is achieved with the new version of the element/standard.
1.2d High Priority will be given to elements/standards for which major changes in any aspects of the Jacobs School may affect compliance.
1.2e High Priority will be given to elements/standards listed in 1.1a (Elements which require monitoring or involve a regularly-occurring process which may be prone to slippage).
1.2h High Priority will be given to elements/standards listed in 1.1c (elements commonly cited by the LCME).
1.2f Moderate Priority will be given to elements/Standards listed in 1.1g (LCME Standards/Elements that monitor and assess achievement of the current Jacobs School Strategic Plans).
1.2g Moderate Priority will be given to elements/standards listed in more than one categories listed in 1.1 unless they are classified as high priority in one of the categories above.
The OAQI will accept for consideration requests for audits from any of the Deans, Chairs of Faculty Council Standing or Select Committees, Chairs for any of the Strategic Plans, a representative from Polity, or any ad hoc committees or taskforces charged with responsibilities dealing with any of the elements or standards listed in Section 1.
A written request must be submitted to the Director of the OAQI which includes the following information:
Contact Dr. Dan Sheehan at firstname.lastname@example.org to request an audit.
The Director of the OAQI shall have the authority to decline a request for audit should any of the following conditions apply:
2.2a The request is received during the 18 month period of active preparation prior to the next accreditation site visit.
2.2b The request is received during the OAQI mid-cycle review process
2.2c The request pertains to an element or standard that is currently in active status of the OAQI monitoring schedule. Results of the OAQI assessment may be given as a substitute to the requested audit results.
Should the Director decide to decline a request for reasons other than listed above, such request and reason for declination will be presented at the weekly Deans’ Meeting for final approval.
In the event that a request for audit has been accepted by the Director, the request, along with proposed tools for measurement or metrics, will be presented at the Deans’ weekly meeting for final decision.
If approved, the OAQI will pursue facts and data from the appropriate sources. Any information gathered will be presented to the requesting body and the Deans in the desired format stipulated in the request.
Where applicable, process mapping will be provided. If desired, the OAQI can work with stakeholders to develop cause and effect diagrams, and assist in the process of quality improvement utilizing the principles of EQUIP Quality Improvement and Lean.
Upon completion, the Deans may recommend continuous monitoring by the OAQI. The OAQI may also, independently, determine a need for monitoring. Updates will be presented to the Deans on a quarterly basis, until the Director has determined the need for monitoring to be fulfilled.
The Office of Accreditation and Quality Improvement will be responsible for providing administrative support and guidance to the Faculty Accreditation Lead (FAL) based on the requirements of the LCME and past experience.
The OAQI will continuously monitor LCME publications for changes in standards and requirements.
During the period of self-study leading up to the accreditation site visit, the OAQI will not begin to monitor any new aspects of the Jacobs School, unless the self-study process uncovers a need for monitoring to achieve compliance with LCME requirements.
The Office of Accreditation and Quality Improvement will be responsible for conducting a Mid-Accreditation-Cycle (MAC) Review over a six month period, at the mid-point between accreditation site visits.
To conduct a MAC review the OAQI will use the most current Data Collection Instrument available from the LCME as a guide to collect and review all information required to ensure compliance with all standards.Results of the MAC review as well as recommendations for methods of improvement in areas where non-compliance is determined, will be presented to the Deans upon completion.
The OAQI may choose to conduct focus groups to garner insight to the driving factors behind results of data collected. The focus group will be conducted by a member of the OAQI or a designate who may be selected for the purpose of maintaining neutrality.
The Deans, Department Chairs, Committee Chairs, and a student representative from Polity may request the OAQI conduct a focus group on their behalf for the purpose of quality improvement.
5.1a The OAQI will work closely with the requestor(s) to formulate questions and select members of the focus group.
5.1b The requestor(s) will be responsible for providing any contact information needed. The OAQI will be responsible for scheduling and communication.
5.1c The requestor(s) shall provide funds to feed the members of the focus group(s). The requestor may choose to select and order the food and beverages provided, or provide the OAQI with a budget to do so.
Want OAQI to conduct focus groups for your team? Fill out a Focus Group Request Form.
The OAQI will exhaust all possible methods to present a complete and accurate assessment of the Jacobs School’s standing for each element/standard. Utilizing any and all reliable data sources is essential to achieving the mission of the OAQI. The OAQI will collaborate with all departments, stakeholders, partners, and members of the Jacobs School community to fulfill its mission.
The OAQI will function most effectively by maintaining partnerships with all members of the Jacobs School. These partnerships will allow individual units to perform continuous quality improvement in their areas as a result of the monitoring, consultation, and support provided by the OAQI.
Standing Committees and senior administrators within the Jacobs School will contribute to the monitoring efforts of the OAQI by assisting in the collection of data, and supporting quality improvement initiatives agreed upon by the relevant stakeholders.
Each individual unit (departments, offices, standing committees, Polity) shall appoint or elect a member to serve as Liaison to the Office of Accreditation and Quality Improvement.
Responsibilities of the Liaison include but are not limited to:
7.2a Act as primary point person for communications between their unit and the OAQI
7.2b Disseminate information released by the OAQI to their unit members
7.2c Ensure submission of requested unit specific information to the OAQI in a timely manner
7.2d Communicate the needs of their unit to the OAQI
7.2e Keep the OAQI informed of their most up to date contact information, and update the OAQI should they pass their role as Liaison to another member of their unit.