Creating a culture of CQI

Continuous Quality Improvement (CQI) – three words that are framing the way forward for the Doctor of Medicine (MD) program and accreditation process – and words you are sure to hear about more often than not at the School.

It may seem like just yesterday the School announced its successful accreditation results for its MD program. In fact, it was two years ago. While the strong showing generated great pride across the School, discussion and planning was initiated shortly afterward to address the elements that were identified as not meeting compliance.

Dr. Michele Weir is taking a leadership role with this work, as the Faculty Lead for accreditation, co-Chair for the Quality Committee and co-Chair of the newly formed Accreditation Committee. Sharing the leadership responsibilities for the Quality and Accreditation Committees is Matt Longstaffe, acting Manager of Undergraduate Medical Education (UME). Longstaffe served as the project manager during the 2015 accreditation.

The Accreditation Committee is comprised of decanal leaders, basic and clinical faculty members, staff from UME and students from Schulich Medicine London and Windsor campuses. They have been working on two tasks. One was to create a plan and oversee action and outcome on the five elements that were identified in 2015 as non-compliant (diversity, service learning, preparation of resident and non-faculty instructors and interprofessional collaborative skills), or compliance with monitoring (assessment systems). In addition, the committee is delivering on a vision of the program and school on continual improvement by reviewing our compliance with each of the new CACMS Elements, and creating recommendations to the Curriculum Committee for action. This is a more realistic process of how we and other Canadian educators see accreditation.

Joining them in this work on outstanding elements are Drs. Gary Tithecott, Kevin Fung and Raj Harricharan, Teresa VanDeven, PhD and representatives from the Social Medicine Course, the Clerkship and Electives Committee, the Diversity Working Group, clerkship rotation directors and interprofessional education leads.

After the initial results were received in 2015, Longstaffe, and Drs. Weir and Tithecott developed and submitted a plan to CACMS (Committee on Accreditation of Canadian Medical Schools), outlining the School’s plan for change.

In 2017, the School was informed that it was in compliance with interprofessional collaborative skills, preparation of resident and non-faculty instructors and the assessment system. Diversity and service learning were moved to compliance with monitoring.

Now, Drs. Tithecott and Jay Rosenfield are charged with ensuring full compliance is achieved with the remaining two elements with evidence submission to CACMS in 2020. Meanwhile the Accreditation Committee will monitor and identify the evidence demonstrating the School becomes compliant with all these elements, the Program is enriched and the experience for our students is the best that it can be.

In 2019, the School will undergo an interim review, where an accreditation lead from another Canadian university will be invited to review the School’s program and progress on the elements.

In this Q&A, Dr. Weir and Longstaffe outline the goals for the Accreditation Committee, what they believe needs to be done, the timing for the next review and the critical importance of this work.

What are the goals moving forward?
We are working together to complete a new two-year CQI cycle, which started in 2016 to review all 96 accreditation elements by the end of the 2018 academic year. We are focused on identifying high-priority and high-risk elements, areas of strength, gaps and improvement opportunities.We are building and updating the Data Collection Instrument (DCI), which is the narrative evidence for each element, in order that a foundational document is complete and does not have to be recreated on short notice. We are also using accreditation monitoring for curricular renewal updates, and developing some strong and effective communication strategies.

What needs to be done to achieve these goals?
The School needs to create a new CQI system to replace the eight-year high resource blip for accreditation, and create a culture of CQI. At the same time, we need to address the new accreditation elements early and continue to focus on how to meet the elements being monitored: especially the elements requiring long term planning like diversity and equity, and social accountability. We also need to prepare for the interim review, taking place in 2019.

When is the next full accreditation?
The next accreditation site visit will take place in 2023. This accreditation will be different from the one in 2015, as it will be completed just by CACMS (previously CACMS and the LCME were engaged together), and will be based on 12 standards with a number of different elements for each standard.

How does this work and accreditation impact people across the School?
In order to be recognized as an undergraduate medical education program, which is compliant with quality parameters, we must have full accreditation status from CACMS. Without this, we will be viewed as not graduating quality MDs and lose our status as a UME program. This impacts our students, faculty, staff, our funding, our communities’ trust and the integrity of our School.

How will you be keeping faculty, staff and students informed on the progress of the School’s work in accreditation?
Each month, we hope to share information through articles in The Pulse newsletter, on the School’s website and through increased visibility online through new web pages and websites.