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.

Leadership lessons from WFME’s past president

Lois Margaret Nora, MD, JD, MBA

I have been interested in leadership since the start of my career, and over the years, other leaders have been some of my most valuable teachers.  Dr. David Gordon, who recently completed his term as president of the World Federation of Medical Education (WFME, Federation), is one of those teachers. 

WFME has played an important leadership role in issues related to medical education since it was organized in 1972.  However, its importance in global education increased dramatically in the wake of a 2010 Education Commission on Foreign Medical Graduates (ECFMG) decision emphasizing the importance of medical school quality around the world and announcing plans to ultimately limit ECFMG certification to graduates of medical schools with accreditation from authorities recognized by the ECFMG. WFME responded by creating a system for recognition of accrediting agencies, by evaluating them against criteria for accreditation and promoting continuous quality improvement.  The criteria were based on standards for accreditation agreed upon at a WHO-WFME meeting in 2005. The Federation was already known for its standards for medical education at the undergraduate, graduate, and post-graduate levels, first published in 2003.

As a medical educator and voluntary assessor with WFME, I’ve seen the impact of WFME’s leadership on quality in medical education. Dr. Gordon has been a driving force behind this work.

When I learned that this important leader was retiring from the WFME presidency, I was delighted to have a chance to speak with him. Dr. Gordon generously shared thoughts on his career, his work at WFME, and the work at the Federation of which he is most proud. 

Lessons from a former medical school dean

Prior to joining and ultimately taking the helm of WFME, Dr. Gordon served as dean of the medical faculty at the University of Manchester, chair of the Council of Heads of Medical Schools of the UK, and President of the Association of Medical Schools in Europe, among other roles. As he spoke with me about his progress though roles with increasing administrative responsibilities, it became clear to me that these experiences — and Dr. Gordon’s experiences as dean in particular — provided exposure to the systems and operational perspectives needed to evolve WFME’s constitution, internal processes, and role in the global medical education community. In fact, the competencies that position medical school deans to succeed were a theme throughout our conversation.

Established by the World Medical Association and the World Health Organization, the Federation works with executive council members and partners in medical education, all of which have important roles in quality higher education, research, and professional medicine. Much like a medical school dean, Dr. Gordon could only deliver on his organizational mission by working to support the success of these and other agencies, such as the Foundation for Advancement of International Medical Education and Research (FAIMER), the International Federation of Medical Students’ Associations (IFMSA), and the Association for Medical Education in Europe (AMEE).

Support for quality and standards in medical education is a central focus of WFME’s work. However, it’s difficult to overstate the complexity of such work on a global scale. It requires a framework with relevance across cultures and medical education systems — regardless of their sophistication and resources — and the skills to work effectively with diverse groups of stakeholders.  As we talked, it became clear to me that Dr. Gordon drew on not just his own experience as he sought to build out this framework, but also on legislative leadership capabilities and a clear understanding of systems thinking, the same skills a medical school dean uses to achieve her mission.

Continuous quality improvement as common ground

A systems-thinking mindset may also explain how WFME has been able to not only manage partnerships with a variety of stakeholders, but also to leverage those same partnerships to deliver on a global mission. For example, WFME works with FAIMER to maintain the World Directory of Medical Schools, a listing of more than 3,750 undergraduate medical education programs. The collaboration unified two separate directories, streamlining data submissions for schools. The result is an integrated resource that meets needs around the world.

As I listened to Dr. Gordon talk about this work, I was reminded that standards and quality in medical education provide common ground for many stakeholders around the world, regardless of their role in healthcare and health professions education. Dr. Gordon’s ability to make the most of this common ground may explain much of his success in support of quality and continuous quality improvement in medical education. 

Relationships and people make the difference

While it’s clear that Dr. Gordon brings the skillset and mindset needed to lead a complicated organization and mission, he continually credited the relationships he formed and the people he worked with for his success. In fact, when I asked him what he’s most proud of, he said it’s his team.

“It’s very satisfying to see people you’ve worked with, and helped, doing really well,” he said.

Having received some of my most important mentoring from WFME staff, I can see what he means. It’s hard to overstate the complexity of building an international team of staff and volunteers that work as seamlessly as WFME’s teams do across international lines. While this success is a credit to many people on WFME’s staff of skilled professionals, it also speaks to leadership. 

My congratulations to Dr. David Gordon on the great work WFME has done on his watch. I am delighted to hear that he will remain in an advisory role with the Federation, which is a duty of the past president under WFME’s constitution. And congratulations as well to new WFME President Ricardo León-Bórquez and his team. I look forward to seeing what’s next for WFME, WFME’s new leadership, and Dr. Gordon himself.

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.