Educational Quality Improvement

​​​​​​​​​​​​​​​​​​Timeline of LCME Accreditation


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Overview of Educational Quality Improvement (EQI) Unit

The Educational Quality Improvement (EQI) Unit within the School of Medicine’s Academic Affairs leads continuous quality improvement initiatives, including the Liaison Committee on Medical Education (LCME) accreditation process. Sara Kim, associate dean for educational quality improvement and research professor of surgery and Marilyn Cope​, director of EQI, are leading the effort. ​

LCME Standards:

The Liaison Committee on Medical Education (LCME) accredits medical education programs leading to the MD degree in the United States and Canada. LCME accreditation is a voluntary, peer-reviewed process of quality assurance. To achieve and maintain accreditation, a medical education program must meet 12 established standards:

  • Standard 1: Mission, Planning, Organization and Integrity
  • Standard 2: Leadership and Administration
  • Standard 3: Academic and Learning Environment
  • Standard 4: Faculty Preparation, Productivity, Participation, and Policies
  • Standard 5: Educational Resources and Infrastructure
  • Standard 6: Competencies, Curricular Objectives, and Curricular Design
  • Standard 7: Curricular Content
  • Standard 8: Curricular Management, Evaluation and Enhancement
  • Standard 9: Teaching, Supervision, Assessment, and Student and Patient Safety
  • Standard 10: Medical Student Selection, Assignment, and Progress
  • Standard 11: Medical Student Academic Support, Career Advising, and Academic Records
  • Standard 12: Medical Student Health Services, Personal Counseling, and Financial Aid Services

Additional information on the specific requirements for compliance for site visits in 2017-2018 can be found in Functions and Structure of a Medical School.

LCME Self-Study and Site Visit

To demonstrate compliance with the 12 standards, a team of LCME peer reviewers participates in a site visit. This visit to the University of Washington School of Medicine (UWSOM) will occur in March 2018.

The review team uses the following sources of information to determine compliance:

Self-Study Report: A report from the UWSOM summarizing its self-review findings.

Data Collection Instrument (DCI): A report that contains UWSOM’s narratives responses to questions as well as data and supporting documentations to demonstrate compliance with the LCME standards​.

Independent Student Analysis: A team of students, independent of the administration, surveys the student body on various educational programmatic aspects and summarize findings in a formal report.​

AAMC Graduate Questionnaire: A survey of graduating medical students conducted by the Association for American Medical Colleges (AAMC). The UWSOM data are benchmarked based on national averages.​

Additional Supporting Evidence: Additional supporting evidence, such as internal data reports, may be provided to the site visit team to demonstrate the program’s compliance with LCME’s standards.

Goals for the Accreditation Process​

​The LCME accreditation process has 5 general purposes:

  1. Regulatory: The achievement or maintenance of accreditation provides access to federal funding, medical licensure of graduates through eligibility for national licensing examinations, and status among peer institutions. 
  2. Continuous Quality Improvement: Through the evolution of the accreditation standards based on peer input and the reflective nature of the self-study, schools are assured of opportunities to improve their programs on a regular basis. 
  3. Organizational Learning Tool: Through their participation on self-study committees, students, faculty and staff have an opportunity to learn about many aspects of their institution. The institution’s designated individuals can also serve as members of national survey teams that visit other medical schools. Site visitors learn from other schools’ solutions to common educational challenges that could generalize to the local educational context. 
  4. Agent of Change: While accreditation standards are typically oriented toward ensuring that basic systems and outcomes are in place at a medical education program, ideally they can also serve to promote efforts on the part of the profession to address areas in medical education that have historically been resistant to change. 
  5. Language for a Culture of Quality: As accreditation standards and elements become widely known and are frequently discussed in the medical education community, they serve to identify areas that require ongoing monitoring or have historically been challenges in medical education. For example, questions such as, “How are we doing with the element 3.3 can be overheard and trigger discussions about the complex issues related to diversity in the learning environment. ​

To learn more about these five purposes, please review the LCME overview​.

UWSOM’s History of Accreditation

The last site visit occurred in March 2010. In its accreditation decision, the LCME elected to continue accreditation of the medical education program for an eight-year term. LCME identified numerous strengths of the program. Partial or substantial non-compliance with the LCME’s standards led the school to strengthen the follow programmatic areas.

  • ​Diversity among faculty and department chairs 
  • Career Counseling 
  • Student Mistreatment 
  • Study and Lounge Space 
  • Affiliation Agreements 
  • Delay in Clerkship Grades

UW Medicine Insight Articles on School of Medicine Accreditation

Contact and LCME Resources

Educational Quality Improvement (EQI) Unit

Dr. Sara Kim, associate dean, Educational Quality Improvement, research professor, Department of Surgery 

​Marilyn Cope, director, Educational Quality Improvement

Treela McKamey, administrative manager, Educational Quality Improvement

​EQI email address:​