Navigating the Road to Reaccreditation
Trends, Resources, and Updates
Donna M. Waechter, PhD
LCME Assistant Secretary
Senior Director, LCME Surveys & Team Training
[email protected]
Goals of the Session
• Recognize the accreditation
standards most commonly found to
be in noncompliance
• Identify resources for completing
the institutional self-study
• Discuss upcoming changes to the
LCME accreditation standards
Secretariat Staff
Dan Hunt (Co-Secretary / AAMC)
Donna Waechter (Assistant Secretary / AAMC)
Barbara Barzansky (Co-Secretary / AMA)
Rob Hash (Assistant Secretary / AMA)
2011-12 Most Common Noncompliance
Citations from Full Survey Reports (n = 25)
1. IS-16
2. ED-30
formative and summative assessment
3. ED-2
required clinical experiences and monitoring
4. ER-9
affiliation agreements
5. MS-27-A
health care providers’ involvement in student assessment
6. ED-33
curriculum management
2011-12 Most Common Noncompliance
Citations from Full Survey Reports (n = 25)
7. ED-24
resident preparation
narrative feedback
8. MS-31-A learning environment and professionalism
student mistreatment
9. ED-8
comparability across instructional sites
10. ED-31
mid-course feedback
use of student evaluation data in program evaluation
Possible LCME Actions Following
a Full Survey Visit
• Continue full accreditation for 8-year term with no
additional follow-up
• Continue full accreditation for 8-year term with
follow-up action(s) - written status reports,
• Continue accreditation with no fixed term pending
outcome of a focused visit
• Continue accreditation and place the program on
• Continue accreditation and place the program on
• Withdraw accreditation
LCME Documents
• All relevant LCME documents are on
the LCME Web site:
• Documents are updated regularly
(check for the most recent version)
• surveyCONNECT for self-study prep
• Connections links each standard to
annotation, self-study guide, and
survey report guide
The Secretariat
The Secretariat answers schools’ questions
several ways:
• Phone 202-828-0596 or 312-464-4933
• Email [email protected]
• Connecting with the Secretariat
• Survey prep workshops
• School consultations
Recent Changes
All information must be included in
the database or provided
to the team onsite
No new information (e.g.,
policies/documents) may be
provided after the team leaves
the school
Categories of Citations
Areas of strength
Particularly noteworthy areas that contribute in a major
way to the achievement of the school’s mission or that
could serve as models; linked to standards
Areas in compliance with a need for
1) A medical education program has the policy, process,
resource, or system required by a standard but there is
insufficient evidence to indicate that it is effective; or
2) A medical education program currently is in
compliance with a standard, but known circumstances
exist that could lead to future noncompliance
Areas of noncompliance
Upcoming Changes
The core curriculum of a medical education
program must prepare medical students to
function collaboratively on health care teams
that include other health professionals.
Members of the health care teams from other
health professions may be either students or
Current Accreditation Standards
132 standards organized into 5 categories:
• Institutional setting
• Educational program
• Medical students
• Faculty
• Resources for the educational program
Reformatting the Accreditation Standards
• Regrouping standards into logical
• eliminate redundancy across current
• reduce the total number of standards
• simplify the self-study database
Reformatting Timeline
• August 2012: concept presented to Standards Subcommittee
• October 2012: concept presented to LCME
• June 2013: final LCME approval
• November 2013: public hearing at AAMC annual meeting
• Spring 2014: medical education database completed
• June 2014: training schools undergoing survey visits in 2015-16