MD: Continuous Quality Improvement


The Liaison Committee on Medical Education (LCME), per element 1.1, expects that a medical school engages in ongoing planning and continuous quality improvement processes that establish short- and long-term programmatic goals, that result in the achievement of measurable outcomes that are used to improve programmatic quality, and that ensure effective monitoring of the medical education program’s compliance with accreditation standards.

Continuous quality improvement is designed to create a seamless system for monitoring and improving medical school programs and should be transparent to all relevant stakeholders. Washington University School of Medicine (WUSM) is committed to exceeding these standards.


A. Monitoring of accreditation standards will be led by the Program Evaluation and Continuous Quality Improvement (PE/CQI) unit in collaboration with appropriate person(s), unit(s) and/or department(s). The following process will take place annually or more frequently as needed:

  1. The data collection instrument element requirements will be sent to the responsible person(s), unit(s) or department(s) who will be asked to review, edit, add and/or remove information that fulfills the required response. The information will be organized and tracked by the PE/CQI unit using various software and project management tools.
  2. The PE/CQI unit will review the submitted information to assess whether the information fulfills LCME and institutional requirements based on research, benchmarking, Secretariat calls, annual internal surveys and Association of American Medical Colleges survey data.
  3. For areas in which WUSM is not meeting expected metrics (as created and vetted with WUSM stakeholders) or when new requirements emerge, a plan of action will be defined including responsible person(s), resources needed, timeline for completion and evidence of improvement.
  4. Results of the improvement plan will be shared with appropriate individuals, administration, and committees such as the Committee on Oversight of Medical Student Education.
  5. The PE/CQI unit will continually monitor the success of the implemented plan to determine if additional improvement is required. 
  6. If conditions of improvement are not met, the concern will be brought to the attention of the Senior Associate Dean for Education for further action.

B. For areas not specifically required by the LCME or the data collection instrument, the PE/CQI unit will use a similar process as outlined above.  

The Continuous Quality Improvement Policy was approved by the Academic Affairs Committee on May 30, 2019. All substantive edits to this policy require approval by the Academic Affairs Committee.