Continuous Quality Improvement | Thomas F. Frist, Jr. College Of Medicine | Belmont University

The LCME-required Continuous Quality Improvement (CQI) Monitoring Cycle is a systematic process used by medical schools to regularly assess, document, and improve compliance with LCME accreditation standards. It ensures that the institution maintains accreditation readiness between formal site visits by:

Monitoring each LCME element on a defined cycle (e.g., annually, biennially, or triennially), based on risk and institutional priorities.
Collecting and reviewing data from relevant stakeholders, institutional databases, and academic units.
Identifying areas for improvement or potential non-compliance.
Developing and tracking action plans to address issues.
Reporting progress to the school’s leadership and CQI task force.

This cycle promotes a culture of continuous improvement and helps ensure that the medical education program remains aligned with accreditation expectations and institutional goals.

Continuous Quality Improvement (CQI)

Our CQI monitoring process ensures ongoing compliance with LCME standards through structured review cycles (annual, biennial, triennial), tracking of newly revised elements, previously cited items, and issues flagged through CQI referrals. All LCME elements are managed through a centralized dashboard overseen by the Director of Accreditation and CQI.

Work plans are reviewed quarterly and must include data sources, action dates, review timelines, and responsible individuals. The CQI Task Force meets monthly to address submitted issue forms, review work plans (with contributors presenting their plans), and develop quarterly reports for leadership. Committee decisions are documented and linked to specific LCME elements to support comprehensive oversight and continuous improvement.

The FCoM Continuous Quality Improvement (CQI) Task Force is a dedicated team that meets monthly to guide and support quality improvement efforts. Members include the Dean, Associate Dean of Medical Education, Director of Accreditation and CQI, one student representative, and two additional members appointed by the Dean.

The Task Force establishes monitoring cycles, assigns and reviews CQI work plans, analyzes outcome data, and produces regular CQI reports. The Director of Accreditation and CQI leads the overall process, maintains internal communication platforms for faculty and staff, and manages the public accreditation website. The Dean ensures CQI policy is implemented, while the Associate Dean of Medical Education oversees adherence.

CQI Task Force Members

Dr. Mark Beard

Thomas F. Frist, Jr. College of Medicine

Dr. Mark Beard, MD

Senior Associate Dean for Medical Education, Associate Professor of Family Medicine

Hope Terhaar

Thomas F. Frist, Jr. College of Medicine

Ms. Hope Terhaar, MA

Director of Accreditation

Anderson Spickard

Thomas F. Frist, Jr. College of Medicine

Dr. Anderson Spickard, MD

Dean, Professor of Internal Medicine and Clinician Educator

John Muise

Thomas F. Frist, Jr. College of Medicine

Mr. John Muise, MA

Student Affairs Manager

Pat Whitworth

Thomas F. Frist, Jr. College of Medicine

Dr. Pat Whitworth, MD

Assistant Professor of Radiology

Haley Rague

Thomas F. Frist, Jr. College of Medicine

Haley Rague

Medical Student YR2

Standards

Element Monitored	Timing of Monitoring	Monitored By
1 Mission, Planning, Organization and Integrity	Annually	Dean, School of Medicine; Provost
1.1 Strategic Planning and CQI	Annually	Dean, School of Medicine; Provost
1.2 Conflict of Interest (COI) Policies	Every 2 Years	Associate Dean for Faculty Success
1.3 Mechanisms for Faculty Participation	Annually	Dean, School of Medicine; Provost
1.4 Clinical Education Agreements	Annually	Dean, School of Medicine; Provost
1.5 Bylaws	Annually	Dean, School of Medicine; Provost; University Counsel at Belmont
1.6 Eligibility Requirements	Every 3 Years	Reviewed for Quality Assurance Only

Element Monitored	Timing of Monitoring	Monitored By
2 Leadership and Administration	Annually	Reviewed for Quality Assurance Only
2.2 Dean’s Qualifications	Every 2 Years	Reviewed for Quality Assurance Only
2.3 Access and Authority of the Dean	Every 2 Years	Reviewed for Quality Assurance Only
2.4 Sufficiency of Administrative Staff	Annually	Dean, School of Medicine; Provost
2.5 Responsibility of and to the Dean	Every 2 Years	Reviewed for Quality Assurance Only
2.6 Functional Integration of the Faculty	Annually	Associate Dean of Faculty Success

Element Monitored	Timing of Monitoring	Monitored By
3 Academic and Learning Environments	Annually	Senior Associate Dean of Medical Education
3.2 Community of Scholars/ Research	Every 2 Years	Dean, School of Medicine; Provost
3.4 Anti-Discrimination Policy	Every 2 Years	Review for Quality Assurance
3.5 Learning Environment/ Professionalism	Annually	Dean, School of Medicine; Provost
3.6 Student Mistreatment	Annually	Dean, School of Medicine; Provost

Element Monitored	Timing of Monitoring	Monitored By
4 Faculty Preparation, Productivity, Participation, and Policies	Annually	Dean, School of Medicine; Provost
4.1 Sufficiency of Faculty	Annually	Dean, School of Medicine; Provost
4.2 Faculty Appointment Policies	Annually	Review for Quality Assurance
4.3 Scholarly Productivity	Annually	Dean, School of Medicine; Provost
4.4 Feedback to Faculty	Annually	Office of Faculty Success, Office of Foundational and Clinical Sciences, CQI Task Force
4.5 Faculty Professional Development	Annually	Dean, School of Medicine; Provost
4.6 Responsibility for Medical School Policies	Annually	Office of Medical Education; Office of Foundational and Clinical Sciences; Office of Faculty Success; Office of Student Affairs and Belonging; CQI Task Force

Element Monitored	Timing of Monitoring	Monitored By
5 Educational Resources and Infrastructure	Annually	Dean, School of Medicine; EVP for Financial Excellence
5.1 Adequacy of Financial Resources	Annually	Dean, School of Medicine; EVP for Financial Excellence
5.2 Dean’s Authority/ Resources	Every 2 Years	Dean, School of Medicine; Provost
5.3 Pressures for Self-Financing	Every 2 Years	Dean, School of Medicine; Provost
5.4 Sufficiency of Buildings and Equipment for the Pre-clerkship Phase of Curriculum	Annually	Dean, School of Medicine; Provost
5.5 Resources for Clinical Instruction	Annually	Senior Associate Dean of Medical Education
5.6 Clinical Instructional Facilities/Information Resources	Annually	Dean, School of Medicine; Provost; Chair of Foundational and Clinical Department; Senior Associate Dean of Medical Education
5.7 Security, Student Safety, and Disaster Preparedness	Annually	Office of General Counsel
5.8 Library Resources/Staff	Every 2 Years	Senior Associate Dean of Medical Education; FCoM Librarian
5.9 Information Technology Resources/ Staff	Every 2 Years	Senior Associate Dean of Medical Education
5.11 Study/Relaxation/Storage Space/Call Rooms	Every 2 Years	Dean, School of Medicine; Senior Associate Dean of Medical Education: Provost
5.12 Required Notifications to the LCME	Annually	Review for Quality Assurance

Element Monitored	Timing of Monitoring	Monitored By
6 Competencies, Curricular Objectives, and Curricular Design	Annually	Senior Associate Dean of Medical Education
6.1 Program & Learning Objectives	Annually	Senior Associate Dean of Medical Education
6.2 Required Clinical Experiences	Annually	Senior Associate Dean of Medical Education
6.4 Inpatient/Outpatient Experiences	Annually	Senior Associate Dean of Medical Education
6.5 Elective Opportunities	Annually	Senior Associate Dean of Medical Education
6.6 Service-Learning/Community Service	Annually	Senior Associate Dean of Medical Education; Associate Dean of Student Affairs and Belonging
6.7 Academic Environments	Annually	Review for Quality Assurance
6.8 Education Program Duration	Annually	Senior Associate Dean of Medical Education

Element Monitored	Timing of Monitoring	Monitored By
7 Curricular Content	Annually	Senior Associate Dean of Medical Education
7.1 Foundational Medical Knowledge	Every 2 Years	Senior Associate Dean of Medical Education
7.2 Patient Care	Every 2 Years	Senior Associate Dean of Medical Education
7.3 Health Promotion and Health Maintenance	Every 2 Years	Senior Associate Dean of Medical Education
7.4 Communication and Interprofessional Collaborative Skills	Every 2 Years	Senior Associate Dean of Medical Education
7.5 Professionalism	Every 2 Years	Senior Associate Dean of Medical Education
7.6 Practice-Based Learning and Improvement	Every 2 Years	Senior Associate Dean of Medical Education
7.7 Systems-Based Practice	Every 2 Years	Senior Associate Dean of Medical Education

Element Monitored	Timing of Monitoring	Monitored By
8 Curricular Management, Evaluation, and Enhancement	Annually	Senior Associate Dean of Medical Education
8.1 Curricular Management	Annually	Senior Associate Dean of Medical Education
8.3 Curricular Design, Review, Revision	Annually	Senior Associate Dean of Medical Education
8.4 Evaluation of Educational Program Outcomes	Annually	Dean, School of Medicine; Senior Associate Dean of Medical Education; Department Chairs; Provost
8.5 Medical Student Feedback	Annually	Senior Associate Dean of Medical Education
8.6 Monitoring of Completion of Required Clinical Experiences	Annually	Senior Associate Dean of Medical Education
8.7 Comparability of Education/ Assessment	Annually	Senior Associate Dean of Medical Education
8.8 Monitoring Student Time	Annually	Senior Associate Dean of Medical Education

Element Monitored	Timing of Monitoring	Monitored By
9 Teaching, Supervision, Assessment, and Student and Patient Safety	Annually	Senior Associate Dean of Medical Education
9.1 Preparation of Resident and Non-Faculty Instructors	Annually	Office of Faculty Success; CQI Task Force
9.1 Preparation of Resident and Non-Faculty Instructors	Annually	Dean, School of Medicine; Curriculum Committee
9.2 Faculty Appointments	Annually	Senior Associate Dean of Medical Education
9.3 Clinical Supervision of Medical Students	Annually	Senior Associate Dean of Medical Education
9.4 Assessment System	Annually	Senior Associate Dean of Medical Education
9.5 Narrative Assessment	Annually	Senior Associate Dean of Medical Education
9.6 Setting Standards Of Achievement	Annually	Senior Associate Dean of Medical Education
9.7 Formative Assessment & Feedback	Annually	Senior Associate Dean of Medical Education
9.8 Fair & Timely Summative Assessment	Annually	Senior Associate Dean of Medical Education
9.9 Student Advancement & Appeal Process	Annually	Senior Associate Dean of Medical Education

Element Monitored	Timing of Monitoring	Monitored By
10 Medical Student Selection, Assignment, and Progress	Annually	Associate Dean of Admissions
10.2 Final Authority of Admission Committee	Every 2 Years	Associate Dean of Admissions
10.3 Policies Regarding Student Selection/Progress and Their Dissemination	Every 2 Years	Associate Dean of Admissions
10.4 Characteristics of Accepted Applicants	Every 2 Years	Associate Dean of Admissions
10.5 Technical Standards	Annually	Dean, School of Medicine
10.6 Content of Informational Materials	Every 2 Years	Associate Dean of Admissions
10.7 Transfer Students	Every 2 Years	Associate Dean of Admissions
10.8 Visiting Students	Every 2 Years	Associate Dean of Admissions
10.9 Student Assignment	Every 2 Years	Senior Associate Dean of Medical Education

Element Monitored	Timing of Monitoring	Monitored By
11 Medical Student Academic Support, Career Advising, and Educational Record	Annually	Associate Dean of Student Affairs and Belonging
11.1 Academic Advising and Academic Counseling	Annually	Associate Dean of Student Affairs and Belonging
11.2 Career Advising	Annually	Associate Dean of Student Affairs and Belonging
11.3 Oversight of Extramural Electives	Annually	Associate Dean of Student Affairs and Belonging
11.5 Confidentiality of Student Educational Records	Every 2 Years	Review for Quality Assurance
11.6 Student Access to Educational Records	Every 2 Years	Review for Quality Assurance

Element Monitored	Timing of Monitoring	Monitored By
12.0 Medical Student Health Services, Personal Counseling, and Financial Aid Services	Annually	Office of Student Affairs and Belonging
12.1 Financial Aid/Debt Mgmt. Counseling	Annually	Office of Student Affairs and Belonging
12.2 Tuition Refund Policy	Every 2 Years	Review for Quality Assurance
12.3 Personal Counseling/ Mental Health/ Well-Being	Annually	Associate Dean of Student Affairs and Belonging; Office of Student Services
12.4 Student Access to Health Care Services	Annually	Senior Associate Dean of Medical Education; Associate Dean of Student Affairs and Belonging
12.5 Non-Involvement of Providers of Health Services in Student Assessment/ Location of Student Health Records	Every 2 Years	Senior Associate Dean of Medical Education
12.6 Student Health and Disability Insurance	Annually	Review for Quality Assurance
12.7 Immunization Requirements and Monitoring	Every 2 Years	Associate Dean of Student Affairs and Belonging
12.8 Student Exposure Policies/ Procedures	Every 2 Years	Office of Environmental Safety; Office of Student Affairs and Belonging

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Thomas F. Frist, Jr. College of Medicine

1900 Belmont Boulevard
Nashville, TN 37212

Phone: 615.460.6191

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