School of Medicine: Office of Medical Student Education: Monitoring Performance of LCME Accreditation Standards

This policy outlines the system established by the UNC School of Medicine (“SOM”) for ongoing monitoring of accreditation standards and elements. It applies to all administrative staff and faculty who are involved with monitoring accreditation standards and elements.

Unit Policy

Title

School of Medicine: Office of Medical Student Education: Monitoring Performance of LCME Accreditation Standards

Introduction

Purpose

This policy outlines the system established by the UNC School of Medicine (“SOM”) for ongoing monitoring of accreditation standards and elements.

Scope

This Policy applies to all administrative staff and faculty who are involved with monitoring accreditation standards and elements.

Policy

Policy Statement

The UNC SOM will monitor ongoing compliance with all Liaison Committee on Medical Education (“LCME”) standards and elements. The LCME Continuous Quality Improvement (“CQI”) Committee has designated authority and responsibility to oversee and manage this effort. To ensure that such compliance is maintained throughout the accreditation cycle of the LCME, a work-plan will be maintained that includes the LCME elements being reviewed in any given academic year, the data sources used for each element, the timing and procedures for data collection and review, and the identification of the individuals /committees who receive and act upon this information. The work plan will be approved by the Dean’s Advisory Committee. 

The work plan may include the following Categories of Elements for Monitoring/Review: 

• Elements that include language that monitoring is required or involve a regularly occurring process that may be “prone to slippage, 
• New elements or elements where LCME expectations have evolved, 
• Elements that include policies that must be congruent with current operations, 
• Elements that directly or indirectly affect the core operations of the school, and 
• Standards/elements that were cited in the medical school’s previous full survey. 

The LCME CQI Team, composed of the faculty director for continuous quality improvement and accreditation and CQI staff are responsible for supporting the ongoing monitoring activities. The dean or their designee assigns personnel and allocates sufficient resources to support the ongoing monitoring effort.

Procedures

The Dean’s Advisory Committee will receive an annual update on the assessment plan results, the use of the results for improvement, and the adequacy of resources to support the ongoing monitoring activities. Changes to the work plan for the monitoring of elements require the approval of the Dean’s Advisory Committee.

Definitions

LCME CQI Committee: the SOM committee responsible for the school’s LCME CQI process. Membership of the committee is composed of the faculty director for continuous quality improvement and accreditation (committee chair), assistant director and/or director of educational effectiveness, senior executive director for academic affairs, faculty accreditation lead, vice dean for education, senior associate dean for medical student education, associate dean for administration, one campus director from regional campuses, and four student representatives from the Student Committee on Accreditation. 

Related Requirements

External Regulations

Liaison Committee on Medical Education (LCME) Functions and Standards of a Medical School  

• Element 1.1: Strategic Planning and Continuous Quality Improvement 

Contact Information

Primary Contact 

Name: Jennifer Maguire, Director for Continuous Quality Improvement and Accreditation 

Email: jennifer_maguire@med.unc.edu

 

Publication Details 

• Issuing Officer: Anthony Passannante, Senior Associate Dean for Medical Student Education
• Effective Date: June 15, 2026
• Next Review Date: June 15, 2028