LCME Accreditation

November 2023:
- USF MCOM received full accreditation by the Liaison Committee of Medical Education until academic year 2030-2031. LCME status report due April 2025.
April 17-19 2023:
- Site visit
February 2023:
- Mock site visit conducted to mirror actual site visit. Consultants held sessions with various stakeholders including students, faculty, and residents to prepare students for what to expect and to inform preparations for the site visit in April.
January 2023:
- The MCOM survey package, including DCI, ISA, and other required accreditation documents will be submitted to the LCME in preparation for the site visit.
- Survey questions were identified to resurvey classes on quality improvement efforts that have occurred to date.
December 2022:
- DME leadership held focus groups with a select group of Year 1-4 classes to gather feedback on several topic areas. Feedback is incorporated into ongoing quality improvement efforts.
November 2022:
- Representatives from the MCOM Office of Financial Aid traveled to Allentown to hold in-person office hours in response to student feedback.
- Comprehensive review of the submitted DCI was held with mock site visit consultants.
October 2022:
- Several DME leaders traveled to Allentown, PA to hold a focus group with a group of SELECT students as part of post-ISA activities.
- Full DCI draft was submitted to mock site visit consultants for review.
September 2022:
- Annual review of AAMC Graduate Questionnaire with relevant stakeholders in support of continuous quality improvement efforts.
August 2022:
- Badges with QR codes were distributed to all student and resident populations. QR codes serve as a one-stop shop for high-yield guidelines, procedures, and other relevant information.
March 2022:
- The Independent Student Analysis committee finalized the ISA report.
- Mock site visit consultants identified.
November 2021:
- The Independent Student Analysis(ISA) survey is closed by the ISA committee. The ISA committee begins the analysis of ISA data and report compilation.
October 2021:
- The Independent Student Analysis(ISA) survey is launched by the ISA committee.
September 2021:
- Morsani College of Medicine hosted the LCME Co-Secratariat, Dr. Veronica Catanese, for the LCME Campaign Kickoff Event. Over 100 attendees joined for an overview of the college's site visit preparations and self-study process.
June 2021:
- Morsani College of Medicine LCME Site Visit Dates Announced for 2023.
May 2021:
- Faculty Accreditation Lead and chairs of the DCI Writing Committee attend the LCME Survey Prep Workshop organized for schools prepping for a 2022-23 site visit.
March 2021:
- Dr. Bryan Bognar named Faculty Accreditation Lead.
February 2019:
- Dr. Deborah DeWaay named Faculty Fellow.

What is LCME?

Every eight years the Liaison Committee on Medical Education (LCME) conducts a voluntary, peer-reviewed process of quality assurance that determines whether a school’s medical education program is in compliance with established nationally-accepted standards of medical education quality. Programs are required to demonstrate that their graduates exhibit general professional competencies that are appropriate for entry to the next stage of their training and that serve as the foundation for lifelong learning and proficient medical care.

Most state boards of licensure require accreditation as a condition for licensure of a school’s graduates. A school must be accredited for students to be eligible to take the USMLE examinations and for their graduates to be eligible for residency programs accredited by the ACGME.

Although the Morsani College of Medicines monitors its educational programs continuously, the accreditation process provides a valuable opportunity for a thoughtful and comprehensive self-assessment of the program and student learning environment. It further allows for the identification of strengths and areas for improvement.

Why is LCME Accreditation Important?

LCME accreditation is required in most states for licensing graduates and receiving federal financial aid. Only graduates of LCME-accredited schools are eligible for residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) purposes.

LCME Building Blocks: Standards and Elements

Standards: concise statements of the expected level of quality or attainment; the “currency” of assurance, with the three coins of “compliance,” “compliance with monitoring,” or “noncompliance” determined by the LCME

Elements: components that collectively constitute a standard; operationally, elements identify variables that must be examined to determine a medical education program’s compliance with a particular standard; each element evaluated as “satisfactory,” “satisfactory with a need for monitoring,” or “unsatisfactory” by the survey teams (but ultimately determined by the LCME)

What data does the school submit to the LCME?

The college prepares three critical components for the LCME survey team to review: the Data Collection Instrument (DCI), which evaluates performance within the LCME’s 12 standards; the Independent Student Analysis (ISA), in which a group of current medical students surveys their peers and compiles a report focused on questions around LCME standards; and the Institutional Self-Study, in which an appointed task force evaluates the DCI and ISA to determine strengths and challenges related to accreditation elements, and outline plans and activities to improve our medical school.

Students are a critical part of data collection and analysis. The impact students have on the overall accreditation process and the opportunities to serve as change-makers cannot be overstated. The data collected from the ISA provides the foundation for action plans that result in immediate changes within the institution, as well as the ability to identify gaps that require longer-term planning and implementation. As a result, students involved in the accreditation process have a significant opportunity to impact the shape of the medical school across all domains. This serves to improve educational outcomes and the student experience.

Students in all years will be asked to complete an independent student analysis (ISA) in which they provide information on 71 different items required by the LCME and on other items developed by student leaders. The LCME requires that at least 70% of each class year respond to the ISA. Student leaders will then provide data from the ISA to incorporate into the DCI as well as provide the data and analysis to the LCME. While the college will assist student leaders in the process, the college is prohibited from suggesting modifications to student conclusions.

Students will also be asked to participate in the LCME task force subcommittee and will also meet with the site visit team.
The self-study process provides a great opportunity for faculty and staff to learn more about the Morsani College of Medicine and commit to our institution’s continuous quality improvement. As the self-study process gets underway, faculty and staff may be asked to provide data for the DCI. You may be asked to book conference rooms or reschedule other meetings to accommodate LCME-related matters. In addition, as we go through the process, we may discover areas that require changes or improvements to implement prior to April 2023. We appreciate your patience, flexibility, and commitment to helping us implement these needs as they arise.
The Independent Student Analysis (ISA) is one of three major sources of student-based information that the LCME survey team will use when it evaluates the medical education program during its site visit. The other two sources of information are the AAMC Graduation Questionnaire (GQ, and the students who meet with survey team members during the survey visit. These students will come from all years of the curriculum but may not necessarily constitute a representative sample of student’s opinions. To complement these other information sources, the ISA should be based on a comprehensive survey of students in all four years and cover a wide range of subjects important to students. Students in all years will be asked to complete the ISA in which they provide information on 71 different items required by the LCME and on any other items developed by the student committee. After the completion of the survey by the students, the committee analyzes the survey data and completes an executive summary report. The ISA and student team members are a core part of our Self-Study process. Not only is much of the data from the ISA required to complete several portions of the Data Collection Instrument (DCI), but the ISA report itself is submitted as part of the accreditation materials sent for review to the LCME.

An accreditation survey is not an opportunity for individual students, faculty members, deans, or anyone else to involve the LCME in discussions about personal or academic grievances with the medical school. As an accrediting agency, the LCME and its survey teams concentrate only on making determinations about whether the medical education program is performing in a satisfactory way related to the accreditation standards and elements.
The accreditation process has two general and related goals: to promote institutional self-evaluation and continuous quality improvement and to determine whether a medical education program meets the requirements and expectations determined by the LCME. During the institutional self-study, a medical school collects, reviews, and analyzes the data requested by the LCME and found in the data collection instrument (DCI). A task force composed of key institutional leaders is formed to direct the self-study process, and various subcommittees are convened consisting of faculty, staff, and students who possess knowledge of the medical education program. The task force and subcommittees identify institutional strengths and areas of concern so that strategies may be enacted to either maintain, enhance or bring about change.

Committees

Committees and subcommittees of the Morsani College of Medicine leadership, faculty and staff have been formed to manage the various LCME processes leading up to the Site Visit. The LCME Task Force will oversee all activities of the reaccreditation process. The following subcommittees will take on extensive duties related to the self-study process:

Self-Study Task Force

The Self-Study Task Force is responsible for analyzing the Self-Study Subcommittees’ and ISA Task Force’s findings and preparing the final self-study summary report and completed database that will be submitted to the LCME.

Self-Study Subcommittees

The Self-Study Subcommittees are responsible for preparing reports on specific areas about the medical education program based on review and analysis of the information provided during the data collection process. The reports prepared by the Self-Study Subcommittees include identified needs and recommendations.

Data Collection Instrument (DCI) Committees

The DCI Committees are tasked with writing up and completing the data collection instrument. Six committees cover the 12 standards.

Independent Student Analysis Committee

The ISA Committee is responsible for developing the survey, promoting it to their peers, analyzing the responses and compiling the final report for UAB leaders. The report is one of the key pieces our school will submit to the LCME for review.

Roadmap to the LCME Site Visit

January 2019-Current

LCME Task Force selects chairs for six DCI writing committees. DCI committees begin monthly meetings to populate DCI, college data for tables and supporting documentation. DCI chairs will also identify and begin corrections for any exposed weaknesses

February 2021

Designate the Faculty Accreditation Lead and Survey Visit Coordinator.

May 2021

Designate team of students to conduct the student survey and write the ISA

August 2021

Begin work with students to generate ISA instrument through research of GQ, requested DCI data, and other sources

September 2021 – December 2021

Complete the DCI to pass on to Self-Study Task Force Subcommittees

October/November 2021

ISA is open

November 2021

ISA Committee submits preliminary data for incorporation into the DCI

January/February 2022

Final ISA Report due

February 2022

Complete the DCI to pass on to Self-Study Task Force Subcommittees

February 2022 – May 2022

Self-Study subcommittees analyze relevant DCI reports, ISA, GQ and results of previous LCME Accreditation; create Self-Study Reports for assigned LCME Standards; continue to correct any exposed deficiencies, incorporate Strategic Plan.

May 2022 – July 2022

Task Force synthesizes and summarizes the work of the Task Force subcommittees and prepares the final self-study summary report

June 2022 – October 2022

Review of final documents
Update DCI and SSSR with 2022 GQ data
Update all DCI tables, narratives, and appendices; Review all materials

September/October 2022

Final check of all materials for completeness, accuracy, voice, internal consistency, etc

October/November 2022

Site Visit Preparation

December 2022/January 2023

Planning Meetings for LCME site visit
Send all materials to LCME

April 17th-19th 2023: LCME site visit

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