University of Vermont University of Vermont Medical Center

Continuous Quality Improvement

The Larner College of Medicine fosters a culture of continuous quality improvement to identify areas for further attention in our effort to provide a medical education second to none.

Monitoring Requirements

The LCME requires that all medical schools report on a set of twelve standards which are pre-defined educational areas. They are identified from the following categories:

Elements that include an explicit requirement for monitoring or involve a regularly-occurring process
New or recently-revised or changes in LCME expectations related to performance in elements
Elements that could be reviewed to ensure that policies are congruent with current operations
Elements that directly or indirectly effect the core operations of the school
Elements that were cited in the medical school’s previous accreditation surveys
Elements that were commonly cited in the last three years
Other elements that were identified through program evaluation processes, the Medical Curriculum Committee, or via Larner School of Medicine leadership

The CQI Committee functions according to the Bylaws of the Faculty of the Larner College of Medicine.

CQI Standard Monitoring

Standard 1: Mission, Planning, Organization, and Integrity

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
1.1 Strategic Planning and Continuous Quality Improvement	Annually	Dean & Senior Associate Deans
1.2 Conflict of Interest policies	Every 3 Years	Dean & Senior Associate Deans
1.3 Mechanisms for Faculty Participation	Every 3 Years	Dean & Senior Associate Deans; Associate Dean for Faculty Affairs
1.4 Affiliation Agreements	Every 3 Years	Dean & Senior Associate Deans
1.5 Bylaws	Every 3 Years	Dean & Senior Associate Deans
1.6. Eligibility Requirements	Every 3 Years	Dean & Senior Associate Deans

Standard 2: Leadership and Administration

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
2.1 Administrative Officer and Faculty Appointments	Every 3 Years	Associate Dean for Faculty Affairs
2.2 Dean's Qualifications	Every 3 Years	Dean
2.3 Access and Authority of the Dean	Every 3 Years	Dean
2.4 Sufficiency of Administrative Staff	Every 2 Years	Dean & Senior Associate Deans
2.5 Responsibility of and to the Dean	Every 2 Years	Dean
2.6 Functional Integration of the Faculty	Every 2 Years	Dean & Senior Associate Deans; Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus

Standard 3: Academic and Learning Environments

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
3.1 Resident Participation in Medical Student Education	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus
3.2 Community of Scholars/Research Opportunities	Every 3 Years	Senior Associate Deans
3.3 Diversity/Pipeline Programs and Partnerships	Annually	Dean & Senior Associate Deans; Associate Dean for Diversity, Equity, & Inclusion
3.4 Anti-Discrimination Policy	Every 3 Years	Dean & Senior Associate Deans
3.5 Learning Environment/ Professionalism	Annually	Dean & Senior Associate Dean for Medical Education
3.6 Student Mistreatment	Annually	Senior Associate Dean for Medical Education

Standard 4: Faculty Preparation, Productivity, Participation, and Policies

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
4.1 Sufficiency of Faculty	Every 2 Years	Dean & Senior Associate Deans; Associate Dean for Faculty Affairs; Chairs
4.2 Scholarly Productivity	Every 3 Years	Dean; Senior Associate Dean for Research; Chairs; Associate Dean for Faculty Affairs
4.3 Faculty Appointment Policies	Annually	Dean; Associate Dean for Faculty Affairs
4.4 Feedback to Faculty	Every 2 Years	Senior Associate Dean for Medical Education; Chairs
4.5 Faculty Professional Development	Every 3 Years	Senior Associate Dean for Medical Education; Senior Associate Dean for Research; Associate Dean for Faculty Affairs
4.6 Responsibility for Medical School Policies	Every 3 Years	Dean & Senior Associate Deans

Standard 5: Educational Resources and Infrastructure

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
5.1 Adequacy of Financial Resources	Every 2 Years	Dean & Senior Associate Deans
5.2 Dean's Authority/Resources	Every 3 Years	Dean & Senior Associate Deans
5.3 Pressures for Self-Financing	Every 2 Years	Dean & Senior Associate Deans
5.4 Sufficiency of Buildings and Equipment	Every 3 Years	Dean & Senior Associate Deans
5.5 Resources for Clinical Instruction	Every 3 Years	Dean & Senior Associate Deans
5.6 Clinical Instructional Facilities/Information Resources	Every 3 Years	Dean & Senior Associate Deans
5.7 Security, Student Safety, and Disaster Preparedness	Every 3 Years	Dean & Senior Associate Deans
5.8 Library Resources/Staff	Every 3 Years	Dean & Senior Associate Deans
5.9 Information Technology Resources/Staff	Every 3 Years	Dean & Senior Associate Deans
5.10 Resources Used by Transfer/Visiting Students	Every 3 Years	Dean & Senior Associate Deans
5.11 Study/Lounge/Storage Space/Call Rooms 55	Annually	Dean & Senior Associate Deans
5.12 Required Notifications to the LCME	Annually	Dean & Senior Associate Deans

Standard 6: Competencies, Curricular Objectives, and Curricular Design

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
6.1 Program and Learning Objects	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
6.2 Required Clinical Experiences	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
6.3 Self-Directed and Life-Long Learning	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
6.4 Inpatient/Outpatient Experiences	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
6.5 Elective Opportunities	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
6.6 Service-Learning/Community Service	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
6.7 Academic Environments	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
6.8 Education Program Duration	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee

Standard 7: Curricular Content

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
7.1 Biomedical, Behavioral, Social Sciences	Every 2 years
7.2 Organ Systems/Life Cycle/Primary Care/Prevention/Wellness/Symptoms/Signs/Differential Diagnosis, Treatment Planning, Impact of Behavioral and Social Factors	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
7.3 Scientific Method/Clinical/Translational Research	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
7.4 Critical Judgment/Problem-Solving Skills	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
7.5 Societal Problems	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
7.6 Cultural Competence and Health Care Disparities	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
7.7 Medical Ethics	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
7.8 Communication Skills	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
7.9 Interprofessional Collaborative Skill	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee

Standard 8: Curricular Management, Evaluation, and Enhancement

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
8.1 Curricular Management, Evaluation, and Enhancement	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
8.2 Use of Medical Educational Program Objectives	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
8.3 Curricular Design, Review/Content Monitoring	Annually	Senior Associate Dean for Medical Education; Medical Curriculum Committee
8.4 Evaluation of Educational Program Outcomes	Annually	Senior Associate Dean for Medical Education; Medical Curriculum Committee
8.5 Medical Student Feedback	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
8.6 Monitoring of Completion of Required Clinical Experiences	Every 2 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
8.7 Comparability of Education/Assessment	Annually	Senior Associate Dean for Medical Education; Medical Curriculum Committee; Associate Dean for Medical Education, CT Campus
8.8 Monitoring Student Time	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee

Standard 9: Teaching, Supervision, Assessment, and Student and Patient Safety

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
9.1 Preparation of Resident and Non-Faculty Instructors	Annually	Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus
9.2 Faculty Appointments	Annually	Senior Associate Dean for Medical Education; Associate Dean for Faculty Affairs, Associate Dean for Medical Education, CT Campus
9.3 Clinical Supervision of Medical Students	Annually	Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus, Medical Curriculum Committee
9.4 Assessment System	Annually	Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus, Medical Curriculum Committee
9.5 Narrative Assessment	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus, Medical Curriculum Committee
9.6 Setting Standards of Achievement	Every 3 Years	Senior Associate Dean for Medical Education; Medical Curriculum Committee
9.7 Formative Assessment and Feedback	Annually	Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus, Medical Curriculum Committee
9.8 Fair and Timely Summative Assessment	Annually	Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus, Medical Curriculum Committee
9.9 Student Advancement and Appeal Process	Every 3 Years	Senior Associate Dean for Medical Education; COA

Standard 10: Medical Student Selection, Assignment, and Progress

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
10.1 Premedical Education/Required Coursework	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Admissions
10.2 Final Authority of Admission Committee	Annually	Senior Associate Dean for Medical Education; Associate Dean for Admissions
10.3 Policies Regarding Student Selection/Progress and Their Dissemination	Annually	Senior Associate Dean for Medical Education; Associate Dean for Admissions
10.4 Characteristics of Accepted Applicants	Annually	Senior Associate Dean for Medical Education; Associate Dean for Admissions
10.5 Technical Standards	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Admissions
10.6 Content of Informational Materials	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Admissions
10.7 Transfer Students	Every 3 Years	Senior Associate Dean for Medical Education
10.8 Visiting Students	Every 3 Years	Senior Associate Dean for Medical Education
10.9 Student Assignment	Annually	Senior Associate Dean for Medical Education; Associate Dean for Medical Education, CT Campus; Associate Dean for Admissions

Standard 11: Medical Student Academic Support, Career Advising, and Educational Records

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
11.1 Academic Advising	Annually	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
11.2 Career Advising	Annually	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
11.3 Oversight of Extramural Electives	Annually	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
11.4 Provision of MSPE	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
11.5 Confidentiality of Student Educational Records	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
11.6 Student Access to Educational Records	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs

Standard 12: Medical Student Health Services, Personal Counseling, and Financial Aid Service

Elements that are Monitored	Standard Monitoring Frequency	Monitored By
12.1 Financial Aid/Debt Management Counseling/Student Educational Debt	Annually	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
12.2 Tuition Refund Policy	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
12.3 Personal Counseling/Well-Being Programs	Annually	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
12.4 Student Access to Health Care Services	Annually	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
12.5 Non-Involvement of Providers of Student Health Services in Student Assessment/Location of Student Health Records	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
12.6 Student Health and Disability Insurance	Annually	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs
12.7 Immunization Requirements and Monitoring	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs;
12.8 Student Exposure Policies/Procedures	Every 3 Years	Senior Associate Dean for Medical Education; Associate Dean for Student Affairs

Other Areas

Elements that are Monitored	Frequency	Monitored By
Vision 2025: Unified Strategic Plan	Annually	Dean & Senior Associate Deans
LCME Independent Student Survey Questions	Every 2 Years	Dean & Senior Associate Deans