Medical school clinical affiliates — from an accreditation perspective

Note to the reader: The piece below addresses something I have been thinking about for some time. As I began preparing these comments, I learned that LCME Co-Secretary Barbara Barzansky had recently discussed this topic in a webinar, Clinical Faculty and the Medical School Accreditation Process, hosted by the Alliance for Clinical Education (find their webinars here). That excellent discussion examined accreditation and clinical education from the perspective of the clinical educator and the clerkship course director.  The comments below are geared toward the accreditation oversight office. I think the perspectives are complementary, and I urge you to watch the recording of the webinar, which can be found here.

Note that the comments below are my reflections. The LCME provides myriad helpful resources for accreditation information, including their Connecting with the Secretariat Webinar series, and I recommend making use of them.  As the LCME has noted on its website, “The LCME Secretariat and the publications on [the LCME] website are the only official sources of information regarding LCME policies, procedures, and issues related to the intent of elements.” – Lois Margaret Nora, MD, JD, MBA

Medical schools are responsible for all aspects of their educational programs, yet evolving models for US healthcare mean that direct oversight of clinical training by the medical education office can be limited. While some schools continue to center clinical training in their own teaching hospitals, it’s increasingly common for schools to have multiple clinical affiliations with hospitals and health systems outside of their direct control and often geographically removed from the school.

While Element 1.4 mentions clinical affiliates specifically, these important partners are best viewed through the lens of multiple LCME standards.  In this note, I share some thoughts on how a variety of standards and elements intersect with clinical training, whether at the school’s home location or a clinical affiliate.

Standard 1: Mission, Planning, Organization, and Integrity

Clinical affiliate partners should be considered in your CQI processes (1.1).  Ongoing communication about accreditation requirements is important, as is sharing of relevant data. For example, if your CQI team is monitoring an accreditation element, are relevant affiliates reporting on the necessary metrics?  And are they getting feedback about their performance on those metrics?  

Element 1.4 is the most obvious LCME accreditation element that deals with clinical affiliations.  This element requires alignment around the allocation of clinical training-related responsibilities on the part of the school and the clinical affiliate.  Periodic review of affiliation agreements provides an opportunity to clarify responsibilities for resources — physical and educational — as well as the shared responsibility of providing a professional learning environment.  

When completing the DCI, start by checking that affiliation agreements are signed and that names, dates, page numbers, and other details from the agreements are reflected correctly in the DCI and its attachments.  The DCI explicitly asks where to find language about specific requirements; make sure that your document is clear and that the page numbers listed are correct.  The AAMC Uniform Clinical Training Affiliation Agreement is a useful document.

Standard 2: Leadership and Administration

If clinical affiliates are part of a regional campus, elements 2.4-2.6 may be involved.  Key considerations include clear reporting lines into and out of the dean’s office, meaningful integration of regional faculty into the committee structure of the school, and adequate resourcing of faculty, education, and student support functions on the regional campus. 

Standard 3: Academic and Learning Environments

A close relationship with clinical affiliates can be a tremendous help in working toward your school’s diversity goals (3.3).  The faculty, residents, and staff at clinical affiliate sites contribute to diversity in the learning environment, and these settings offer students opportunities to experience a variety of clinical care settings.  Affiliated residency programs also offer an opportunity to build forward-leaning pathway programs (medical school to residency to faculty).

When a school is experiencing challenges with the learning environment and/or student mistreatment (3.5, 3.6), the clinical environment is often implicated.  Ensure that there is a clear policy stating that mistreatment and retaliation are not tolerated and that the school makes faculty and residents aware of this policy.  Student mistreatment issues should be reported centrally, even if handled locally, and there must be clear protocols for follow-up when issues are reported.  Incorporating questions about faculty and resident professionalism (similar to those on the AAMC Graduation Questionnaire) in your annual student survey can offer important insights beyond those gathered through individual student reports alone.  

Concerns about professionalism may be handled in different offices, depending on the source of the complaint (patient, student, resident, staff, etc.) and the subject of the complaint (attending physician, nursing staff, employee, resident, student).  Offices that handle complaints are appropriately concerned about confidentiality and fairness to all parties.  However, bridging information silos when appropriate may be helpful for ensuring issues are fully recognized and addressed. Hence, communication channels between the school and the affiliate offices that handle issues of professionalism should be in place. 

In addition to identifying issues, schools and clinical affiliates should consider systems-level approaches to challenges in the learning environment.  Professionalism and mistreatment matter to both the school and its clinical affiliates, and jointly sponsored communication and education may be helpful. Some schools have found cross-institutional UME-GME committees valuable for addressing and creating meaningful faculty development opportunities around professionalism in the clinical learning environment.   

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

Element 4.1 speaks to the adequacy of faculty. Attention to this topic in terms of faculty numbers and availability at clinical affiliate sites during clerkships is important, as is a clear process for orienting them to their roles, their responsibilities and the relevant policies they must follow.  Oftentimes, faculty at affiliate sites serve on a voluntary basis.  While Standard 4 focuses heavily on traditional, salaried faculty, aspects of this standard are important for voluntary faculty, as well.  Work published by voluntary faculty at affiliate sites can be included in your scholarly productivity data (4.3).  Faculty appointments should be current, and faculty should receive meaningful feedback on their performance.  Many voluntary faculty aspire to promotion, and pathways for promotion in their faculty track should be available.

Standard 5: Educational Resources and Infrastructure

Standard 5 includes many elements that relate to clinical affiliates.  These elements can be particularly challenging to manage, given that they are often outside the direct control of the medical school.  However, the school remains responsible, even where direct oversight is limited.

Elements 5.5, 5.6, 5.8, 5.9, and 5.11 speak specifically to resources available for clinical education.  Patient volumes vary over time, and this can often be handled by adjusting student numbers on a given service.  Note that the tables in the DCI should reflect the number of patients by clinical discipline.  More often, issues arise over the adequacy of call rooms and space for secure storage, relaxation, and education.  Hospitals are under real space constraints.  Providing clarity about expectations — to all involved — is important. Elaborate student-only lounges are not expected; access to secure storage space and reasonable study and relaxation space is.

Element 5.7 deals with safety and security, and the school should be comfortable with security at all clinical locations.  The safety of students in parking lots after hours is one of the most frequent concerns, and access to security escorts can go a long way toward resolving it.  Particular attention should be paid to clinical rotations where students may encounter violent patients or angry family members.  Ensure students are oriented to safety protocols at the various hospitals and establish guidelines that require security-related episodes to be reported to the main campus.

Standards 6-9: Competencies, Curricular Objectives, and Curricular Design; Curricular Content; Curricular Management, Evaluation, and Enhancement; Teaching, Supervision, Assessment, and Student and Patient Safety

Teaching and assessment elements to keep in mind for clinical affiliates involve comparability of the education program across sites (8.7); mechanisms for identifying issues that may interfere with completion of required clinical experiences (6.2); expectations involving mid-clerkship feedback and timely submission of grades (8.6, 9.8); meaningful formative feedback (9.7); and availability of policies on these and other key topics (e.g., supervision (9.3), duty hours (8.8)).  Ensuring that expectations are met across affiliate sites requires ongoing communication and benefits from collegial working relationships among education leadership, faculty, and staff at the affiliate sites and the central medical education office.  Technology assistance, standardized operating procedures, and clear communication channels can help ensure adherence to policies.  Central monitoring of many of these activities can provide early warning if they are not being done or, conversely, provide evidence that they are occurring if student data suggests otherwise. 

Central monitoring is also important to ensure that residents have been appropriately trained in methods for teaching and/or assessing students (9.1) and that faculty and residents are provided with information about learning objectives and policies.  Even if residents are in a hospital or hospital system outside the school’s direct control, it is important to ensure that you are comfortable with that institution's resident-as-teacher program and that their residents receive and understand the school’s relevant policies.  Use central monitoring to prospectively ensure that physician-teachers have a current faculty appointment before they are assigned students (9.2). Clinical faculty and other nonfaculty educators, such as respiratory therapists and midwives, must be aware of and follow expectations regarding the teaching and supervision of medical students (9.3).

Standards 10-12: Medical Student Selection, Assignment, and Progress; Medical Student Academic Support, Career Advising, and Educational Records; Medical Student Health Services, Personal Counseling, and Financial Aid Services

When students spend substantial time away from campus completing educational requirements, including training with clinical affiliates, it is important that they have demonstrably comparable access to and quality of student support services as students have on campus (11.1, 11.2, 12.1, 12.3, 12.4). Videoconferencing, telehealth, and remote counseling services can be helpful.  We recommend that schools follow up with students who access services remotely to ensure these alternative means of access are effective. 

Clinicians who provide healthcare to students or have another close relationship with students should not have a role in the education/assessment of those students (12.5).  This includes situations where a student wishes to complete an elective in a family member’s practice or return to their pediatrician for an elective.  And there must be a clear — and clearly communicated — process for handling student education-related injuries such as needlesticks in a timely manner, particularly after hours (12.8).

Increasingly, schools are using attestation as a mechanism to demonstrate that residents and faculty are aware of the school’s policies, have received professional development, and are adhering to the requirements outlined in certain elements. This approach may be helpful for demonstrating compliance with these and other components of the LCME standards, provided care is taken to ensure attestation reflects a true understanding of policies and procedures, rather than functioning as a check-the-box exercise.

Making the most of your school’s partnerships

One of the most interesting and challenging aspects of accreditation, particularly for the medical school professionals who play a leading role in the process, is navigating accountability for issues over which they may have little direct control. This is a particular challenge with respect to clinical affiliations.

From my experiences serving as a voluntary clinical faculty member and then as faculty accreditation lead through my years of observing and supporting accreditation professionals, I have seen time and time again the value of legislative leadership skills (e.g., communication, consensus-building, and creating shared mental models, among others). These skills enable us to understand the goals and limits faced by our colleagues at affiliate organizations, clarify our institution’s needs, and build shared models to accomplish our intersecting missions.  Consider, for example, a joint medical school-affiliate learning environment committee that bridges both organizations, as well as undergraduate and graduate medical education. Or a joint working group that addresses issues in the care environment. The benefits of such collaboration typically go well beyond an immediate goal such as compliance with accreditation standards.   

Strong relationships with clinical affiliates frequently benefit when accreditation professionals leverage another leadership skill:  leading up.  Hospital leaders have their own priorities for the use of a facility’s limited space, and a senior medical school leader may be most effectively positioned to point out the shared common goals of accreditation compliance and quality in medical education.  Your ability to engage the dean or vice dean to take the lead on these issues at the appropriate time is important.

I hope these comments and suggestions help underscore the many ways clinical affiliate medical school relationships matter from both an education and student services perspective, and I welcome your input — including anything important that I might have missed.

3 ways to make the most of your curriculum committee meeting minutes

Lois Margaret Nora, MD, JD, MBA

The LCME has long asked schools to include two years’ worth of curriculum committee meeting minutes for site visitor review during the medical school accreditation process. More recently, they have started requesting that these documents be searchable.

Minutes themselves cannot be changed. However, some simple steps — and a thoughtful approach to future meetings — can help optimize these documents for review by accreditors and, as importantly, for memorializing the committee’s work for the school itself.  

Speak the language of the LCME

Schools understandably have internal terminology that speaks to their history, culture, and processes. Sometimes these align closely with LCME terminology, but not always. Consider a term the LCME might be looking for in your curriculum committee minutes, such as program outcomes. Your committee may be reviewing these outcomes, but if minutes do not use this term, a search for “program outcomes” will turn up nothing of note — potentially suggesting a gap in the committee’s work.

Deliberately integrating LCME terminology into your minutes will help ensure that a site visitor who searches your documentation lands on all the relevant content. One way to do this is to start using the LCME terminology throughout your minutes. Explicitly use terms from the elements and standards like program outcomes (8.4), narrative assessment (9.5), mid-clerkship feedback (9.4), and formative assessment (9.6). 

Leverage keywords

The approach described above works for optimizing minutes going forward. But some schools will be sharing minutes from meetings that have already been completed. To optimize existing minutes, a different approach is needed.

Consider revisiting past minutes to see if key search terms are used.  If so, no changes are needed. However, if you find that key topics were discussed but these references are unlikely to be found with a search that uses LCME terminology, you can consider assigning keywords to the corresponding minutes based on the content of the meeting. Borrowing from the previous example, if minutes indicate that cohort data on course performance, NBME results, and residency program director surveys were discussed in a meeting, a keyword such as program outcomes could be attached to the minutes, enabling a site visitor to quickly locate the documentation. 

The prospect of sifting through old meeting minutes to make them more accessible for searching may be overwhelming, but it does not necessarily require intensive word-for-word review. One simple place to start is by looking at the agenda for each meeting. Identify the themes, scan the notes to ensure the themes were in fact discussed (and that documentation is adequate), then add the relevant keywords or phrases.  Remember that meeting minutes should not be changed.  However, the curriculum committee can decide to add a “keywords” section to the minutes and direct that past minutes (at least for the past year or so) be reviewed so keywords can be added. Agreement around the addition of keywords should also be documented in the minutes from the meeting at which that decision is made. 

As your team aligns around keywords, these can also be assigned for future meetings to keep themes top of mind and accessible, and presentation of minutes consistent.

Include the right level of detail

When reviewing the content of your meeting minutes, it is a good idea to also review your process for meeting minutes more generally to ensure it is serving the committee and school as well as possible.  For example, some committees document meeting activities in such a limited way that the minutes reflect little other than that the issue was discussed.  Other committees document activities exhaustively (e.g., even to the level of a complete transcript) to ensure nothing gets lost. Both types of minutes can create problems.

We recommend including enough detail in minutes to truly inform future readers about the nature of a discussion without burying key points. A simple sentence noting which issues the committee discussed does not tell the reader what really happened in a meeting, but a full transcript may not adequately spotlight the most important pieces. Consider documenting the themes that were discussed, with a reasonable amount of detail about each: the perspectives considered, the consensus achieved, and which next steps were identified.

Thinking beyond curriculum committee minutes and accreditation

Although the LCME only requires the submission of searchable curriculum committee minutes at this time, schools may also benefit from applying the ideas discussed above to other committee minutes. Consider the CQI committee, for example. Schools monitor work on a variety of LCME elements as part of CQI, and these activities are often discussed in meetings. If your school is working toward enhancements to the academic advising program, for example, a quick search of well-optimized CQI committee minutes could pull up the date and reasons for starting on the initiative, the steps taken to enhance academic advising functions, and the outcomes documented as a result. Such information could be helpful for demonstrating compliance with CQI requirements and more importantly, telling the story of your institution’s ongoing improvements.

The complexity of accreditation — and indeed medical school administration — means processes large and small can make a difference in your ability to complete work, achieve your goals, and avoid burnout. Meeting minutes may be under the radar of many professionals, but leaders who embrace opportunities to examine and optimize processes of all types are well-positioned to improve the function of their teams and reinforce a culture of continuous quality improvement.

Element 3.3: Takeaways from a recent LCME webinar

It has been a goal of mine to use this blog to foster information sharing across the medical education accreditation community.  So, I was thrilled when Dr. Polly Hofmann accepted my invitation in the last newsletter to submit a piece for this space. She describes her takeaways from a recent LCME webinar that outlined upcoming changes to accreditation expectations involving Element 3.3.

The LCME webinars are an invaluable resource for medical education professionals, and we share this post in an effort to amplify the LCME’s work and support schools that are closely examining their diversity and inclusion efforts in light of recent federal and state legislative changes.  Note that Dr. Hofmann, MSAG, and this space do not represent that we are or that we speak for the LCME.

As the LCME has noted on their website, “The LCME Secretariat and the publications on [the LCME] website are the only official sources of information regarding LCME policies, procedures, and issues related to the intent of elements.” Anyone who has specific questions may wish to direct them to the Secretariat. 

– Lois Margaret Nora, MD, JD, MBA

Dear Colleagues,

The LCME Secretariat Webinar in March focused on the upcoming changes to Element 3.3, Diversity Programs and Partnerships.  These changes impact student and faculty diversity efforts, and they will be incorporated into the 2025-2026 Data Collection Instrument (DCI).  The changes were, in part, a response to the Supreme Court ruling that race-based college admissions policies are in violation of the Constitution.  This ruling was accompanied by a landslide of legislative activity related to diversity in various states. Thus, the LCME reconsidered Element 3.3 to ensure all schools would be able to meet accreditation requirements without being in conflict with state and federal law.  The following describes my takeaways from the points presented, along with a synopsis of the webinar Q&A.

Addressing Student Diversity

After offering some historical perspective, the Secretariat discussed changes to how diversity is handled.  A formal policy with diversity categories is no longer required. However, tables in the 2025-2026 DCI will continue to require school-identified diversity categories for students with reporting of outcomes in offers and enrollment in the MD program. Further, a diversity pathway program(s) with tracking of outcomes continues to be required. A new narrative response question in the 2025-2026 DCI will be “Describe how the medical school expresses its commitment to the value of diversity in the academic learning environment and aligns this commitment with its mission.”1 Thus, a “mission statement, strategic plan, or policy must demonstrate the school’s commitment to the value of diversity in the academic learning environment.”1

The Secretariat and LCME recognize that some schools may elect to change their student diversity categories and, as such, have minimal outcomes data to support the efficacy of a given activity.  For example, a school may shift from presenting 10 years of data on outcomes associated with race-conscious efforts to presenting limited data on efforts focused on students from underserved ZIP codes and/or students of lower socioeconomic status.  A reduction in available data is expected with a change in diversity categories and, depending on the specifics of that school, would at most warrant monitoring by the LCME.  In a nutshell, the LCME values diversity, but also offers flexibility to schools to select their unique student diversity categories based on the mission of the school.  Please note, the LCME does not prohibit schools from continuing to have race or gender as part of their school-identified diversity categories.  However, early and clear communication by schools with their own General Counsel and system leadership about their student diversity categories is recommended.

Addressing Faculty Diversity

Faculty and senior administrator diversity categories and related reporting of outcomes have been eliminated from the 2025-2026 DCI. Consistent with this, tables in this portion of the DCI have been modified to remove faculty and senior administrators. In addition, Element 3.3 will now read:

“A medical school has effective policies and practices in place, and engages in ongoing, systematic, and focused recruitment and retention activities, to achieve mission-appropriate diversity outcomes among its students, faculty, senior administrative staff, and other relevant members of its academic community. These activities include the use of programs and/or partnerships aimed at achieving diversity among qualified applicants for medical school admission and the evaluation of program and partnership outcomes.”1 (Strike-through added to show exact text to be removed). 

To address the important role of faculty in diversity, the LCME added a new narrative response to the 2025-2026 DCI.  Specifically, “Describe how the medical school ensures that its faculty and senior administrative staff are prepared to support its diverse student body. How does the school determine that this support is adequate and effective?”1

For Schools Shortly Undergoing Review

The Secretariat provided direction to schools that are actively preparing for a survey visit and using the 2024-2025 or older DCI.  They clarified that Element 3.3 performance, starting immediately and through June 2025, “will be based on the following:

• Mission statement, strategic plan, or policy that demonstrates the school’s commitment to the value of diversity in the academic learning environment

• Mission-aligned diversity categories for students and tracking of recruitment outcomes

• Pathway programs and partnerships, and tracking of program outcomes”1

In addition, effective immediately, schools do not need to have a policy defining the student diversity categories on their website.

Questions and Answers (paraphrased)

Q: Given that the public will have the opportunity to provide feedback about the changes in Element 3.3, what happens to these planned DCI changes if comments are extensive and concerning?

A: Any change to the DCI requires 18 months to go through proper vetting.  As such, the 2025-2026 DCI changes as presented will be going forward.

Q: What will happen to schools already given an unsatisfactory for Element 3.3 based on a failure to, for example, collect outcomes data on faculty diversity or any such information or programs that are no longer required in the 2025-2026 DCI? 

A: These schools will have their final report amended, and the citation will be expunged.  They will not be required to respond to the citation in the school status report.  However, caution is warranted as some citations involving Element 3.3 are based on criteria that will continue to be needed for accreditation.  As an example, outcomes data for pipeline programs aimed at increasing the number of diverse student applicants is still required.  If a school is unsure whether they should respond to a 3.3 citation, the Secretariat should be consulted.

Q: For schools about to undergo a self-study or site visit using an older DCI, will Element 3.3 tables and narrative responses related to faculty and senior administrators still be a part of their upcoming review?

A: No, the LCME will no longer look at or take this information into consideration. Further, schools that have not yet completed the Element 3.3 tables specifically related to faculty and senior administrators may leave those table cells blank and instead provide a notation like “Given that the LCME is no longer looking at this information, it was not collected and reported.”

Q: Is it required that the word “diversity” be used in response to Element 3.3.

A: No, a synonym or descriptive phrase is acceptable as long as the principle or concept is preserved.

Q: How far out do schools need to track students in pipeline programs?

A: For college students, it is reasonable to look at whether they went on to apply to medical school.  For pipelines that work with younger students, such as high school students, the outcomes might include how they rated the program and how it affected their next step, e.g., college enrollment.

I encourage those who are interested in this topic to download the webinar slides from the LCME website.  The revised tables and narrative responses are presented.

— Polly Hofmann, PhD

Professor & Senior Executive Associate Dean of Faculty Affairs Emeritus

University of Tennessee College of Medicine

1 Connecting with the LCME Secretariat Webinar, March 7, 2024.  Speakers Veronica Catanese, MD, MBA; Barbara Barzansky, PhD, MHPE; Robert Hash, MD, MBA.  Slides can be found at https://lcme.org/event/mar-2024-connecting-webinar/

Adequately resourcing administrative staff

Lois Margaret Nora, MD, JD, MBA

When a former colleague and I had lunch recently, we began discussing an issue that has long challenged medical education leaders: Insufficient administrative support. As my colleague discussed her own perspective at a business organization, I recognized that this issue is widespread and has consequences for the quality of our work and for the well-being of our teams.

Skilled support personnel such as office reception staff and administrative assistants are critical to the function of any leadership team. It’s difficult to overstate the importance of their assistance with scheduling, planning, document preparation, and representation of the team within and beyond the institution.  These individuals can also be a wonderful source of advice and institutional knowledge, and they may offer a safe space for discussion of and counsel on sensitive issues. Such professionals serve a pivotal role in identifying issues that need to be addressed, getting work done well and on time, and networking across the institution.

While it may be appropriate for administrative support professionals to function as a shared support system for a team, I have noticed that administrative support professionals are increasingly assigned to multiple senior leaders who have significant responsibility in an organization. In recent years, there has been a dramatic expansion in many schools of career advising, academic advising, and CQI functions, all of which require administrative support systems. While these changes appropriately include new decanal staff, I am not convinced there has been a consistent and commensurate expansion of support staff.  

A few consequences can result.  Administrative support professionals who answer to multiple leaders may be forced to prioritize among those they assist, setting the team up for possible conflict when time is short and deadlines are approaching. Overworked administrative professionals may struggle to maintain the quality of their work, hurting perceptions of customer service, not to mention the outcomes of the work itself.

These issues can also contribute to a sense of isolation and difficulty taking time off, creating a potent well-being challenge for administrative support personnel. The whole team inevitably feels the strain.  Others on the team may have to set aside work that only they can do to meet administrative needs, adding to inefficiency across the office.  It’s difficult for senior leaders to be as effective as possible if they are frequently pulled into administrative tasks that do not require their expertise, and their well-being may suffer, as well.

Blending my medical education accreditation work with my role as a change-maker coach for the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, I have been working to identify intersections between well-being and accreditation. While the LCME does not explicitly set requirements for administrative support staffing, Element 2.4 sets an expectation that staffing will be adequate for supporting the mission of the school. In addition, the LCME expects offices such as Medical Education and Student Affairs to be accessible and for those professionals to be aware of and responsive to student concerns.  In my experience, student dissatisfaction often relates to limited administrative support and/or rapid turnover in staff, rather than any lack of diligence or caring among the people in those offices.

For the health of the team as well as optimal accreditation outcomes, I advise professionals to spend some time examining their administrative support staffing levels to ensure adequacy. Questions that may help stimulate this discussion include:   

• Has your team’s workload grown? Consider how your class size and/or program load compares with 10 years ago.

• Has the size of your support staff grown concurrently with the expansion of middle management?

• Have people been promoted to middle management without shedding their administrative support roles? Internal development and promotion are things to celebrate, but some new managers may need additional support to meet the expectations of their new jobs.

• Are people across your team working at the top of their expertise, or are they handling tasks that take time away from their most important work?

• Are there staffing guidelines available for your area of work? Some organizations, such as the National Association of Student Financial Aid Administrators, set benchmarks for staffing that may be helpful. When considering such benchmarks, keep in mind that issues faced by medical and other graduate students can have unique complexities that may influence staffing needs.

• Review your results from the AAMC GQ and any annual student surveys your school is conducting. If you are maintaining your DCI regularly as we have suggested, you can start by reviewing the latest information there. If scores related to the availability and responsiveness of staff in areas like career counseling, academic advising, and financial services suggest there are problems, consider whether the teams in those offices are overextended and could benefit from enhanced administrative support.

Hopefully, these conversations will spark meaningful ideas for supporting your full team and the work they do. These discussions will also likely inspire ideas for supporting administrative support professionals themselves. Here are five that I think are particularly important:

• Ensure adequate staffing: As discussed above, inadequate administrative support staffing puts a strain on everyone, particularly administrative support professionals themselves. These colleagues often manage entry points to our offices; if they cannot function effectively, we can expect concerns about accessibility.

• Keep an eye on compensation: It’s worth looking at benchmarks for salaries across your team, especially as workloads expand. Administrative support professionals who have not received promotion-related compensation changes may warrant particular attention. Make sure pay reflects the value these professionals bring to the team and the school.

• Engage the full team in planning: The institutional knowledge and perspectives of administrative support professionals bring unique value to goal setting and strategic planning. Meaningful inclusion of these professionals in such processes is critical to maximizing results.

• Encourage professional development: Growth is not just about promotion. Ensure your administrative support staff has access to professional development opportunities — and your full support for taking time away from day-to-day work for these activities. The whole team will benefit from this investment in professional skills and satisfaction.  

• Celebrate your team: Recognizing contributions across the team is a tenet of good leadership. Be sure your administrative support staff has the same opportunities as others to celebrate your office’s achievements, and be sure to acknowledge the great work these professionals do every day.

It’s not difficult to imagine how administrative support professionals become overloaded with work. The most skilled of these professionals make balancing many complex tasks and priorities look easy. However, real problems can result when these colleagues are stretched too thin. As accreditation professionals work to address problems that may link to the effectiveness of senior leaders, ensuring staffing adequacy and appropriate attention to the needs of administrative support professionals may be a helpful place to start.

Professional development in accreditation: Attending to CQI on a personal level

Lois Margaret Nora, MD, JD, MBA

A question I am often asked when people learn of our consulting group’s support for schools going through accreditation is “How do you recommend we keep up?”  Numerous standards, crossing all areas of the medical education program; annual updates of standards, elements, and the Data Collection Instrument (DCI); questions about how the standards and elements are interpreted and whether those interpretations change over time … these are a few of the things that cause concern.

Like all else in our professional lives, keeping up requires a commitment to ongoing learning and professional development.  Fortunately, resources for medical education professionals who are interested in accreditation have proliferated over the past few years.  Here is some of the advice I offer when asked about keeping up in this area.

• To educate yourself and your team, plan an annual review of changes to the LCME standards and elements as well as revisions to the DCI. As we have suggested previously, you can couple this process with an annual update of your school’s DCI. This is a great opportunity to remain well informed about the standards and on track for continuous quality improvement (CQI) between accreditation cycles, and it will also position you to educate colleagues across the school. The Medical Education and Student Affairs offices as well as the CQI committee will need to be aware of changes across all the standards and elements, while other committees and specialized offices (e.g., Student Health, Finance, and Registrar) may find a more focused discussion most helpful. 

• The accreditation-related sessions at AAMC meetings are always of great value.  And do not hesitate to take advantage of the LCME Secretariat’s offer of private consultation opportunities during the AAMC meeting.  Ongoing communication with the Secretariat through these sessions — and by phone or email during other times of the year — is valuable as questions arise and is particularly important if a school is contemplating substantial changes to its medical education program.  This proactive interaction can be an excellent source of learning, and it is a crucial step for ensuring any major changes are planned with accreditation implications in mind. I’m also excited about the AAMC meeting opportunities related to CQI and accreditation scholarship presented by our colleagues.  These are burgeoning areas of scholarship in medical education over the past few years.  

• Attend the regularly scheduled Connecting with the LCME Secretariat webinars.  The schedule of topics and dates can be found on the LCME website.  I have been surprised to learn that some people think these webinars are primarily useful in the period leading up to a survey visit — actually, they are terrific anytime in the accreditation cycle.  All the webinars will be useful for accreditation/CQI professionals and leaders of major areas in Medical Education and Student Affairs.  These professionals can, in turn, share the learning by spreading the word about scheduled topics that may be relevant to other offices at their schools. 

• One of the most valuable professional development opportunities for accreditation/CQI professionals that has emerged in the past several years is the CGEA Program Evaluation & Accreditation Special Interest Group. While this SIG began in the Central Group of GEA (my first professional home in medical education!), it has rapidly expanded into a national community.  Their monthly meetings span a variety of topics.  I’m particularly excited about this group, as I hope it can provide an important feedback loop to the LCME that allows schools' experiences, concerns, and questions to be conveyed to accreditors.

• Certain professional development opportunities are particularly important at key points in the accreditation cycle.  Schools should attend the orientation meetings sponsored by the LCME as they begin their self-study.  And the LCME’s Faculty Fellows program is a valuable source of learning for current or prospective faculty accreditation leads.

At MSAG, professional development is a regular part of our work. While we take part in many of the activities I have mentioned, we have other ongoing professional development — both informal and formal.  Much of our informal professional development relates to learning from one another as part of our team approach to our work.  We also have formal professional development focused on our own CQI.  Examples include regular review of feedback collected by an independent quality assurance professional following each consulting engagement, presentation of relevant literature, focused discussion of one or more elements, and professional development on a topic such as language and demeanor during a mock site visit. 

Those of us who work in accreditation are called to it for a variety of reasons. Passion — whether for improving patient care through improved health professions training; for education and making it the best it can be; or for quality improvement and the role accreditation plays — has often brought us to this work.  Passion is an important motivator, but to do our best work, we must continue learning.  That’s why ongoing, lifelong professional development is so valuable.  I am delighted to see the growing emphasis on professional development in accreditation and CQI, and I welcome your ideas about additional ways we can all work together to continue our growth.

Best practices for making the LCME DCI part of your ongoing continuous quality improvement

Lois Margaret Nora, MD, JD, MBA

It’s no exaggeration to say that at many medical schools, there are few projects more challenging than preparing the Data Collection Instrument (DCI) ahead of an LCME accreditation site visit.  The full DCI questionnaire for the 2023-24 academic year numbers more than 150 pages, and it covers every aspect of medical school operations. Organizing, drafting, reviewing, and completing a DCI is a monumental job whose importance is difficult to overstate.

Updating such an important document after not touching it for years can be overwhelming. And yet, that is the experience at many schools.  However, it doesn’t have to be that way, and at MSAG we recommend a different approach. If schools reframe the DCI as a tool for continuous quality improvement (CQI) and then weave it into regular CQI processes, the document becomes not only easier to manage, but also a more accurate representation of the school and its medical education program. It becomes a tool for evaluating and memorializing institutional progress on strategic goals while supporting ongoing compliance with the LCME standards.  

While MSAG has long advocated that schools make the most of their work on the DCI, best practices for doing so come to us from medical educators and administrators.  I was fortunate to speak with two such colleagues recently about this topic.

Dr. Susan Perlis recently retired from her role as associate dean for medical education at Cooper Medical School of Rowan University, and Dr. Tim Gilbert is associate dean for accreditation and planning at the University of South Alabama College of Medicine. Both are seasoned administrators who have extensive backgrounds in education and multiple accreditation systems, providing a wealth of experience to draw on as they work with the LCME framework.

In a recent call, we discussed challenges, best practices, and lessons learned in their years of work with the DCI, and they shared many ideas that could benefit other schools. Here are some of the points I found particularly interesting.

Foster a constructive accreditation mindset

Accreditation is fundamentally about ensuring our institutions train physicians effectively, manage resources appropriately, and serve their communities well. What could be more worthy of our time? However, the challenging and time-consuming processes involved mean accreditation is sometimes viewed as an obligation, rather than an opportunity.

Sue suggests schools reframe their thinking. While pursuing her own research into assessment, she encountered an idea that transformed her thinking about the topic: Accreditation is a process that is done for a school, and not to a school.  “That creates a paradigm shift in the way we think about accreditation. Because if you think about accreditation that way … it becomes something we do for ourselves. For our quality, for our students, for our faculty, for our institution.”

There is a lot to the accreditation process, but one of the biggest hurdles is completion of the DCI. That’s why Tim and Sue have developed processes to keep the DCI up to date.  This work has enabled each of them to reframe DCI revisions and accreditation as a whole as more constructive, positive endeavors. And as Tim notes, this work has also fostered a wonderful spirit of teamwork as colleagues move toward their common goals.

Build a system – and a schedule – for keeping the DCI up to date

Sue and Tim have each created a system for revising the DCI on an annual basis, which they say enables ongoing CQI and streamlines the process of preparing for a site visit when reaccreditation is on the horizon.

When the new DCI is published, Tim has someone on his staff review the questionnaire to note any changes to the elements before turning to content experts for substantive updates. Then, his office works with stakeholders across the school to review one of the 12 standards each month. At any point in time, no part of the DCI is more than 11 months away from update, and someone is always working on it. “We have somebody who is in the DCI at least weekly, if not daily,” he said. The benefits are myriad, but one of the most obvious is simply keeping it current so anytime it’s needed, it’s ready.

Initially, Tim’s team worked on an academic-year schedule, starting with Standard 1 in July, but this year, as part of their own office-wide CQI, they are modifying the schedule to better align with the schedules of stakeholders across the institution. The revised schedule allows completion of Standard 5 (Educational Resources and Infrastructure) to better align with the fiscal year, and Standards 10-12 are completed during quieter times for colleagues in Admissions and Student Affairs. “We simply asked all those stakeholders, what’s the best time of year for you? And that’s how we’re doing it for next year,” Tim said.

Sue’s work on Standards 6-9 involved a flexible schedule as well, and she and her colleagues spent time copying information into the new DCI and highlighting changes and key questions before distributing the document to content experts for revision.  She included notes about what survey teams would be looking for, so contributors could think through how their responses would be read.  Timelines were set for making changes, but they were generous enough to accommodate other necessary work.

Lean on the right mix of expertise – and a teamwork approach

The breadth and depth of material covered by the DCI means no single team can handle it all. As Sue and Tim described their approach to the DCI, it became apparent that partnership is key.  They contribute deep expertise in education, accreditation, and assessment, and colleagues across the institution provide key subject matter expertise needed to fully populate the DCI.

At both medical schools where Sue worked, her primary collaborators beyond her team were faculty committee chairs, who had oversight over the activities documented in the DCI. While the faculty had ownership over the curriculum, Sue brought expertise in the LCME standards to help ensure conversations about changes to the curriculum occurred in the context of the DCI.  This collaboration ensured any possibility that plans might cause issues with compliance was dealt with before ideas were implemented. “Wherever I was, I would make sure I kept the element in front of us, and if a change was made — by the curriculum committee or by the academic standing committee — then I made sure we went back into the DCI and updated that.”

Tim also relies on a mix of accreditation and subject matter expertise for DCI updates. His process also engages reviewers from the CQI committee who bring a CQI lens and an objective perspective to the content. This system means the school has gone from a small handful of people reviewing the DCI to dozens of people offering input. “One of the unintended outcomes and real benefits we didn’t expect was a broadening of understanding of the DCI,” he said. As a result, when teams across the school consider making changes such as a schedule adjustment, implications for the DCI are top of mind. “We’ve got literally dozens of people who take ownership of the DCI, and it’s really reduced the complaining about the accreditation process because they understand it.”   

Leverage the support of leadership

One of the trickier aspects of building a system for regular use of the DCI is the extent to which people who don’t report to you must contribute. I’ve proposed that legislative leadership skills and systems thinking are an important aspect of gaining cross-departmental buy-in for challenging work. Sue and Tim clearly bring both to their efforts to make the most of the DCI.

However, strong support from institutional leadership is also important. Tim said his office enjoys clear support from his dean, which has made it far easier to build the team he needs and the influence to work effectively with other departments. Sue echoed that sentiment.  The importance of the dean’s support “can’t be overstated,” she said.  “It makes all the difference.”

Embrace the teaching and learning opportunity

My conversation with Sue and Tom underscored the deep expertise accreditation professionals bring to their work. Our discussion also served as a reminder of how valuable it can be for accreditation professionals to spend time sharing that knowledge and experience with others whose expertise may lie elsewhere.  When Tim joined his current institution, he saw an opportunity to build the team he needed and took it upon himself to train and promote a staff member who ultimately became an important voice of expertise on accreditation in her own right.  Likewise, Sue built expertise on her teams with a combination of direct teaching and comments on the DCI as the team worked to update it.

When I reflected on my conversation with Tim and Sue, I was reminded that an up-to-date DCI can be a great tool to orient new employees and for job candidates to learn about an institution. I have encouraged mentees to request and read the most recent LCME summary report as they consider job opportunities; a request for the DCI may also result in helpful insights.  As Sue notes, the DCI is really “the nuts and bolts of how we conduct business in a medical school,” making it a rich resource for anyone who needs to become familiar with the institution.

The accreditation process as opportunity

At MSAG, we believe thoughtful standards in medical education support the integrity of our educational programs and help improve the quality of care provided to patients. We also believe medical educators who embrace the CQI opportunity inherent in LCME accreditation will leverage that work to improve, grow, and achieve strategic goals that go well beyond compliance with standards.

Regularly reviewing and updating the DCI may sound like a lot of work, and it certainly does take time, intention, and commitment. However, schools can get much more out of the process than they put in. Accreditation becomes a more positive endeavor that continually benefits the school, rather than a process seen as a periodic and time-consuming burden.

Many thanks to Dr. Sue Perlis and Dr. Tim Gilbert for sharing how they have operationalized these ideas. Input from other colleagues is always welcome, so please reach out anytime with thoughts, questions, and ideas. We will continue to share insights and lessons here on this blog.

Putting accreditation on the faculty retreat agenda – why and how

Lois Margaret Nora, MD, JD, MBA

It’s common during the summer months and the early weeks of fall for medical schools to host annual educational retreats for faculty – both those who are employed and those who teach on a voluntary basis. These events provide a chance for attendees to connect and share information. They also provide an opportunity for leaders from across the school to express appreciation for the invaluable work done by faculty, bring attendees up-to-date on what’s new at the school, and provide faculty development opportunities.

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A recent discussion about planning content for such a retreat reminded me that these gatherings offer a wonderful opportunity to help faculty learn more about LCME accreditation. Members of the faculty may not be aware of the ways in which accreditation expectations affect their work.  For example, a school faces real challenges from an accreditation perspective if narrative feedback is not provided or if evaluations are not submitted in a timely manner. Drawing a link between policies for student assessment and accreditation can help faculty understand the importance of following those policies. It can also help convey how expectations that may feel picky or onerous have real importance for the institution.

This is where the leadership of accreditation professionals comes in.  While accreditation is never far from the minds of those who deal with these processes regularly, it takes work to keep it on radars across the school and beyond high-profile periods like site visits. Talking with faculty about the role they play in accreditation and its importance to the school is one step in the right direction. And retreats, with their collegial atmosphere and attention to learning, may be just the right environment.

Integrating accreditation into retreat content plans

As retreat planners consider how to integrate accreditation into learning, it may help to draw cues from the accreditation cycle itself. Schools that are embarking on a self-study are at a very different place from schools that are years away from reaccreditation. The treatment of accreditation topics in retreat curricula should be adapted accordingly. Here are a few thoughts that may inspire ideas for your planning:

Considerations for schools in a self-study

If a school is poised to begin a self-study, consider focusing the entire retreat around this process.  Start by explaining how the school is accredited and outlining the timing and benchmarks involved (document submission, site visit timing, etc.)  It can be worthwhile to review past accreditation challenges, along with unique aspects of the school that may draw questions from the site visitors, such as distributed campuses or past issues with the learning environment.  Breakout groups can explore specific areas within student support, diversity, faculty affairs, and the educational program.  Involving key committee chairs and members can reinforce the importance of these discussions.

When schools are in the middle of the self-study process, consider sharing early findings from the process and discussing actions being taken to address these findings. Accreditation professionals can present topics themselves, but often this information is best presented by the faculty leaders and area administrators who work directly in these areas. 

Discussions about accreditation can help prepare faculty for conversations with the site visit team by helping them understand what they may be asked about and related expectations for compliance. These discussions also allow medical education professionals to draw a clear line between the everyday work of faculty and the accreditation process. And, importantly, they may open the door to a broader discussion of continuous quality improvement (CQI). The actions of noting red flags through student feedback, GQ and ISA responses or other sources; considering possible changes and then implementing them; and defining how the institution will follow up on outcomes are powerful illustrations of CQI.  Underscoring this message may help foster the collaboration needed for accreditation – and for improving the quality of medical education at your institution.   

Considerations for midcycle schools

Although accreditation is a common topic of concern at schools that are working on a self-study, most schools are elsewhere in the accreditation cycle.  While it can be tempting to set compliance considerations aside after reaccreditation is achieved, there are plenty of midcycle tasks —  CQI; ensuring policies and procedures are up-to-date; and building systems to support compliance — that are important and worthy of discussion at any point in the cycle.

Including an accreditation component in all annual retreats allows for review of this ongoing work.  Doing so also keeps accreditation top of mind. New expectations and standards, feedback about progress addressing past findings, and a conversation about the school’s CQI processes are all worthy topics for discussion.

There are numerous possible approaches realizing these ideas. Consider planning a short, focused session that covers accreditation “highlights.”  Conversely, accreditation could be woven throughout the retreat by asking all speakers to take a few minutes to provide an update within their area of focus (e.g., student support, faculty affairs, curriculum, etc.) Or, for retreats with a specific theme, look for ways in which that theme intersects with accreditation to inspire ideas.

Schools should pursue the approach that makes the most sense for their retreat and their institution. However they proceed, they will derive great value from involving the school’s accreditation professionals in retreat planning.  The unique lens brought by accreditation professionals is about more than preparing the school to do what is necessary for compliance. It’s also about helping the school leverage the LCME standards and processes for improving the quality of medical education at the institution.

Underscoring the value of accreditation, and the accreditation professional

At MSAG, we believe continual reinforcement of the value and principles of accreditation keeps the standards front and center at the school and enhances the quality of the education it provides.

Keeping accreditation top of mind also helps integrate accreditation professionals into the life of the school. As accreditation professionals are given (or create) opportunities to talk about how their work links to priorities across the institution, they clarify their role and value as helpful colleague, while positioning themselves as a resource on a topic of great importance to their institution.