1. LCME and GME New Program Directors’ Meeting – November 15, 2016
Nadia Ismail, MD, MPH, MEd
Associate Dean, Clinical Sciences
Ricky Mercado
Accreditation and Special Projects Coordinator

2. What is LCME and Why is it Important?
The Liaison Committee on Medical Education (LCME) is the nationally recognized accrediting authority for medical education programs leading to the M.D. degree in U.S. (and Canada).
LCME is sponsored by the Association of American Medical Colleges and the American Medical Association.
The LCME accreditation process has two general aims:
to certify that a medical education program meets prescribed standards, and
to promote institutional self evaluation and improvement.  RM

3. Course/Clerkship Directors
Multiple Modalities!!!
Medical Students, Faculty, Residents
-In Person (Dept. meetings, orientation)
Course/Clerkship Directors -
-Leadership Meetings (Dept. Chairs)
Dean’s Office
-Online Module (Future)
-In Person (Orientation)
GME NI

4. Required Evidence Email/Blackboard Online Module Completion
Meetings: Agenda, Sign-in Sheet, Minutes
Near Future: Evidence will be required to be submitted to Dean’s Office for centralized tracking NI

5. LCME Element 1.1 Continuous Quality Improvement
STRATEGIC PLANNING AND CONTINUOUS QUALITY IMPROVEMENT
A medical school engages in ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve programmatic quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards. RM

6. LCME Element 3.5 Learning Environment/Professionalism
A medical school ensures that the learning environment of its medical education program is conducive to the ongoing development of explicit and appropriate professional behaviors in its medical students, faculty, and staff at all locations and is one in which all individuals are treated with respect. The medical school and its clinical affiliates share the responsibility for periodic evaluation of the learning environment in order to identify positive and negative influences on the maintenance of professional standards, develop and conduct appropriate strategies to enhance positive and mitigate negative influences, and identify and promptly correct violations of professional standards. RM
Describe how these professional attributes are made known to faculty, RESIDENTS, and others in the medical education learning environment.

7. LCME Element 3.6 Student Mistreatment
A medical education program defines and publicizes its code of professional conduct for the relationships between medical students, including visiting medical students, and those individuals with whom students interact during the medical education program. A medical school develops effective written policies that address violations of the code, has effective mechanisms in place for a prompt response to any complaints, and supports educational activities aimed at preventing inappropriate behavior.
Describe how medical students, RESIDENTS, faculty and appropriate staff are informed about the medical schools’ standard of conduct in the faculty-student relationship and about medical student mistreatment policies.
Summarize the procedures used by medical students, faculty, or RESIDENTS to report observed incidents of mistreatment and unprofessional behavior in the learning environment.
Describe recent educational activities for medical students, faculty, and residents that were directed at preventing student mistreatment.
Compact Between Teachers, Learners, and Educational Staff RM

8. LCME Element 3.6 Student Mistreatment
Mistreatment Policy: Coming Soon!
Multiple ways to report:
EthicsPoint
Integrity Hotline
End-of-course evaluation
In-person RM

9. 2016 AAMC Survey RM

10. Bi-Annual Mistreatment SurveyRM

11. LCME Element 6.1 Program and Learning Objectives
The faculty of a medical school define its medical education program objectives in outcome-based terms that allow the assessment of medical students’ progress in developing the competencies that the profession and the public expect of a physician. The medical school makes these medical education program objectives known to all medical students and faculty. In addition, the medical school ensures that the learning objectives for each required learning experience are made known to all medical students and those faculty, residents, and others with teaching and assessment responsibilities in those required experiences.
Describe how medical education program objectives are disseminated to each of the following groups:
Medical Students
Faculty
RESIDENTS
Describe how learning objectives for each required course and clerkship are disseminated to each of the following groups:
Core Competency Graduation Goals RM

12. LCME Element 6. 2 Required Clinical Experiences & 8
LCME Element 6.2 Required Clinical Experiences & 8.6 Monitoring of Completion of Required Clinical Experiences
6.2: The faculty of a medical school define the types of patients and clinical conditions that medical students are required to encounter, the skills to be performed by medical students, the appropriate clinical settings for these experiences, and the expected levels of medical student responsibility.
Describe how medical students, faculty, and RESIDENTS are informed of the required clinical encounters and skills.
8.6: A medical school has in place a system with central oversight that monitors and ensures completion by all medical students of required clinical experiences in the medical education program and remedies any identified gaps
Summarize when and how each student’s completion of clerkship-specific required clinical encounters and skills is monitored by the following individuals, including whether the results of monitoring are discussed with the students as part of a mid-clerkship review:
The student’s attending physician, SUPERVISING RESIDENT, preceptor
The clerkship director NI

13. LCME Element 8.8 Monitoring Student Time
The medical school faculty committee responsible for the medical curriculum and the program’s administration and leadership ensure the development and implementation of effective policies and procedures regarding the amount of time medical students spend in required activities, including the total number of hours medical students are required to spend in clinical and educational activities during clerkships
Describe how polices relating to duty hours are disseminated to medical students, RESIDENTS, and faculty.
UME Policy: Duty hours, including all in-house call activities, must be limited to an average of 80 hours per week over a four-week period. Duty periods may be scheduled to a maximum of 24 hours of continuous duty in the hospital. An additional four hours may be spent to ensure appropriate, effective and safe transition of care.  Minimum time off between scheduled duties is 10 hours. Students must also receive a minimum of either 24 hours off per seven-day work period, or four days off per 28-day work period.  NI

14. LCME Element 9.1 Preparation of Resident and Non-Faculty Instructors
In a medical school, residents, graduate students, postdoctoral fellows, and other non-faculty instructors in the medical education program who supervise or teach medical students are familiar with the learning objectives of the course or clerkship and are prepared for their roles in teaching and assessment. The medical school provides resources to enhance residents’ and non-faculty instructors’ teaching and assessment skills, and provides central monitoring of their participation in those opportunities.
Describe any institution-level (e.g., curriculum committee, GME office) policies that require the participation of RESIDENTS and others (e.g., graduate students, postdoctoral fellows) in orientation or faculty development programs related to teaching and/or assessing medical students.
How does the medical school ensure that all RESIDENTS who supervise/assess medical students, whether they are from the school’s own residency programs or other programs, receive the objectives and the necessary orientation?
Table | Resident Preparation to Teach
Briefly summarize the preparation program(s) available to residents to prepare for their roles teaching and assessing medical students in required clinical clerkships. For each program, note whether it is sponsored by the department or the institution (D/I), whether the program is required or optional (R/O), and whether resident participation is centrally monitored (Y/N), and if so, by whom. Add rows as needed.
Program Name/Brief Summary
Sponsorship
(D/I)
Required/
Optional (R/O)
Centrally
Monitored? (Y/N)
Monitored By Whom?
Family medicine
Internal medicine
Ob/Gyn
Pediatrics
Psychiatry
Surgery
Other (list): NI

15. LCME Element 9.3 Clinical Supervision of Medical Students
A medical school ensures that medical students in clinical learning situations involving patient care are appropriately supervised at all times in order to ensure patient and student safety, that the level of responsibility delegated to the student is appropriate to his or her level of training, and that the activities supervised are within the scope of practice of the supervising health professional.
Copy of any policies or guidelines related to medical student supervision during required clinical activities that ensure student and patient safety (e.g., policies about timely access to, and in-house availability of, attending physicians and/or RESIDENTS). NI

16. LCME Element 9.4 Assessment System
A medical school ensures that, throughout its medical education program, there is a centralized system in place that employs a variety of measures (including direct observation) for the assessment of student achievement, including students’ acquisition of the knowledge, core clinical skills (e.g., medical history-taking, physical examination), behaviors, and attitudes specified in medical education program objectives, and that ensures that all medical students achieve the same medical education program objectives.
UME Policy: BCM faculty participating in core clerkships must conduct direct observation of medical students during clinical encounters with patients for the purpose of performing student assessments and providing feedback. During clinical encounters, faculty members must directly observe part or all of a patient's history and mental/physical exam.
Direct Observation Policy NI
Table 1. Required Number of Direct Observations
Clerkship Length
Minimum # of Direct Observations
4 weeks 1
8 weeks 2
12 weeks 3

17. LCME Element 9.7 Assessment and Feedback
The medical school’s curricular governance committee ensures that each medical student is assessed and provided with formal formative feedback early enough during each required course or clerkship to allow sufficient time for remediation. Formal feedback occurs at least at the midpoint of the course or clerkship. A course or clerkship less than four weeks in length provides alternate means by which a medical student can measure his or her progress in learning.
UME Policy: All BCM Course Directors are responsible for ensuring that faculty members who teach, facilitate, or precept medical students provide verbal or written midterm feedback, including an overall evaluation of a student’s progress towards completion of course requirements, in order to allow the student sufficient time for remediation. In the core clerkships, Course Directors ensure that faculty members provide written midterm feedback using the Midterm Feedback and Evaluation Form.
Midterm Feedback Policy NI

18. LCME Element 9.8 Fair and Timely Summative Assessment
A medical school has in place a system of fair and timely summative assessment of medical student achievement in each course and clerkship of the medical education program. Final grades are available within six weeks of the end of a course or clerkship.
UME Policy: BCM Course Directors in the School of Medicine shall submit final grades to the Office of the Registrar within four weeks of the end of a course.
Grade Submission Policy NI

19. LCME Element 12.4 Student Access to Health Care Services
A medical school provides its medical students with timely access to needed diagnostic, preventive, and therapeutic health services at sites in reasonable proximity to the locations of their required educational experiences and has policies and procedures in place that permit students to be excused from these experiences to seek needed care.
Describe how medical students, faculty, and RESIDENTS are informed of policies that allow students to be excused from classes or clinical activities in order to access health services.
Attendance and Participation NI

20. LCME Element 12.5 Non-involvement of Providers of Student Health Services in Student Assessment
The health professionals who provide health services, including psychiatric/psychological counseling, to a medical student have no involvement in the academic assessment or promotion of the medical student receiving those services.
Describe how the medical school ensures that a provider of health and/or psychiatric/psychological services to a medical student has no current or future involvement in the academic assessment of, or in decisions about, the promotion of that student. Describe how medical students, RESIDENTS, and faculty are informed of this requirement. NI

21. Curriculum Renewal November 18th – Curricular Renewal Kickoff
All invited
8-9 – Eva Aagaard from University of Colorado
9-10 – Christner Curricular Renewal Talk
10-12 – Small Group Activities
Create Task Force by December 1
Populate Subcommittees by April 1