SURVEY REPORT GUIDE FOR LIMITED LCME SURVEY VISITS DURING THE ACADEMIC YEAR

Transcription

1 SURVEY REPORT GUIDE FOR LIMITED LCME SURVEY VISITS DURING THE ACADEMIC YEAR LIAISON COMMITTEE ON MEDICAL EDUCATION

2 Survey Report Guide for Limited Accreditation Surveys Liaison Committee on Medical Education Copyright June 2015 by the American Medical Association and the Association of American Medical Colleges. All rights reserved. All material subject to this copyright may be photocopied for the noncommercial purpose of scientific or educational advancement, with citation. i

3 For additional information, contact: LCME Secretariat Association of American Medical Colleges 655 K Street, NW Suite 100 Washington, DC Telephone: LCME Secretariat American Medical Association 330 North Wabash Avenue Suite Chicago, IL Telephone: Visit the LCME website at ii

4 LCME Survey Report Guide for Limited Accreditation Surveys, Page 1 INTRODUCTION The report of an accreditation survey is the formal record of the survey team s findings. It serves as the primary source of information for accreditation decisions by the Liaison Committee on Medical Education (LCME ). Each survey team must take ensure that all its findings are fully explained and documented in the body of the report, and that all elements that the survey team was charged to review are accounted for. The survey report is based on information contained in the briefing book submitted by the medical education program and any additional information that was provided to the survey team on-site. The medical school will be asked to carefully review the draft survey report to ensure that it is factually correct for the time during which the survey visit took place. No new information will be considered for addition to or modification of the report after the survey team concludes the visit. Surveyors should validate the information in the briefing book. It is important to note whether the areas of concern that led to the survey visit have been addressed and whether any new concerns recently have emerged. OVERVIEW: PROCESS FOR THE PREPARATION AND REVIEW OF THE SURVEY REPORT The survey team secretary will assign individual team members responsibility for completing specific sections of the report. These should be drafted during the visit or sent to the team secretary within 7-10 days after the visit concludes. The team secretary and the chair should require team members to use this guide when preparing their individual sections and to use the guidelines for report preparation contained in the Style Guide at the end of this document. The team secretary should develop the report using the survey report template. The team secretary is expected to complete the draft report shortly after the visit (six weeks is optimum). The secretary is responsible for organizing and editing the contributions from the other team members to ensure that the overall report is complete, coherent, logical, and internally consistent. If important areas have been omitted from a team member s write-up, it is the team secretary s responsibility either to contact that member for additional details or to supply the missing content. The team secretary should carefully proofread the draft report to correct typographical, grammatical, and punctuation errors before submitting the report for initial review (see below). The team secretary also should edit the report for the propriety of any attributions of comments made during the survey visit to individual faculty members, administrators, or students. Although the comments of individuals who met with the team may be important for documentation, citation of the source of such specific comments in the report should typically be avoided. The review process for reports is as follows. Both LCME Co-Secretaries should receive a copy of the narrative of the draft report for an initial review before the draft is sent to the team and the school. The draft report narrative should be sent by to <lcmesecretariat@aamc.org>. There is no need to send the appendix materials; the LCME Secretariat will ask for a copy of the appendix materials, if needed. After the team secretary has received feedback from the Secretariat, the report should be modified, as necessary. It is expected that the team chair and secretary will take the Secretariat comments very seriously and make the recommended changes. The report should then be distributed to each member of the survey team and to the dean of the medical school. The team secretary should ask for return of any comments within 10 working days. If feedback from team members requires changes in the report s findings, tone, or content that the dean has not had an opportunity to review, the team secretary should call the dean or send revised pages for decanal review before finalizing the report.

5 LCME Survey Report Guide for Limited Accreditation Surveys, Page 2 The communication with the dean that accompanies the draft report should include the statement that only information that was included in the DCI or provided to the team on-site will be considered during the review of the report, even if the information (e.g., the policy) existed at the time of the survey visit. See Survey Visit Information for teams < for sample language to include in the communication with the dean. The dean should specifically be asked to correct, by or in writing, any errors of fact and to describe any concerns about the tone of the report. If there are no corrections, the dean also should state that fact in writing. The team chair and secretary should attempt to resolve any disagreements that the dean may have with the tone or content of the report. The dean should be informed of the changes that have been, and have not been, made in the report. If the dean has remaining concerns about the tone of the report or the process of the visit, he or she should be invited to write a letter to the LCME Secretariat. No new information may be provided and no attachments will be accepted. The dean s letter would be included in the meeting agenda and considered along with the survey report when the LCME evaluates the program s accreditation status. The final, corrected report (with the appendix) should be sent electronically to the LCME Secretariat offices, along with copies of all correspondence between the team secretary and the dean regarding the draft report. See Style Guide for Report Preparation at the end of this document for details about how to format and submit the final report. The team secretary should be aware of two important timing issues regarding survey reports: that LCME meetings typically are held early in October, February, and June and that LCME members must have access to the final report a minimum of four weeks before the meeting. This requires that the team secretary submit the final report to the LCME Secretariat at least four weeks before a scheduled LCME meeting. COMPLIANCE DEFINITIONS It is the responsibility of the survey team to make a recommendation to the LCME about the status of each of the elements reviewed during the visit. Survey teams do not make judgments about compliance with accreditation standards; that is the purview of the LCME. Teams should use the following definitions when making this determination for each element under review: Satisfactory: The required policy, process, resource, or system is in place and, if required by the element, there is evidence to indicate that it is effective. Satisfactory with a Need for Monitoring: 1) The medical education program has the required policy, process, resource, or system in place, but there is insufficient evidence to indicate that it is effective. Therefore, monitoring is required to ensure that the desired outcome has been achieved. 2) The performance of the medical education program is currently satisfactory, but known circumstances exist that could lead to future unsatisfactory performance. Unsatisfactory: The medical education program has not met one or more of the requirements of the element. The required policy, process, resource, or system either is not in place or is in place but has been found to be ineffective.

6 LCME Survey Report Guide for Limited Accreditation Surveys, Page 3 THE REPORT OF A LIMITED ACCREDITATION SURVEY INTRODUCTION A limited (focused) survey is conducted when concerns of a serious nature have been identified, for example, during a full survey visit, and the LCME believes that a survey visit is necessary to review the corrective actions that have been taken by the medical school. In general, the team conducting a limited survey should focus on the specific areas prompting the visit. However, any substantive new problems that are identified during the limited survey visit also may be examined and reported by the team. BACKGROUND In preparation for the limited survey, the school is sent a letter by the LCME Secretariat about six months prior to the survey visit. The letter describes the information related to the areas previously cited as not in compliance (noncompliance)/unsatisfactory and as in compliance with a need for monitoring/satisfactory with a need for monitoring that should be included in a briefing book for the survey team. The letter for surveys during the academic year organizes the requested information according to the standards/elements adopted for use starting in Note that the full survey that served as a stimulus of the limited visit likely used the former 132 accreditation standard. The information in the briefing book is used by the survey team to provide supporting documentation for the text and appendix of the limited survey report, similar to the DCI in a full survey visit. The survey team should review carefully the school s previous accreditation history, including the prior full survey report and any interim status reports. The team secretary should work with the school to organize the visit schedule to focus on the issues highlighted in the letter of accreditation to the school following the full survey. LIMITED SURVEY REPORT FORMAT [Use the template for the report of a limited survey and note that instructions/comments are embedded in the template in italics. These should be deleted from the template as the report is drafted] COVER PAGE. Use the cover page from the survey report template, adding specific details such as school name and survey date. TABLE OF CONTENTS (including that for the Appendix). Use the model Table of Contents in the report template for a limited survey. Make sure that all Appendix documents are listed. The report should be paged sequentially, including the Appendix but note that the template contains embedded numbers (I and ii) for the table of contents. MEMORANDUM (from the survey team secretary to the LCME). Use the sample in the survey report template. The memorandum is page 1 of the survey report.

7 LCME Survey Report Guide for Limited Accreditation Surveys, Page 4 INTRODUCTION AND COMPOSITION OF THE SURVEY TEAM A typical example: A survey of the University of Eastchester School of Medicine was conducted on December 1-4, 2011, by an ad hoc team representing the Liaison Committee on Medical Education (LCME. After the introductory sentence, complete the section in the survey report template that lists the members of the survey team, with their names, titles, and institutions, as well as their roles on the survey team as chair, secretary, member, faculty fellow, or observer: Chair: Abraham Lincoln, MD Dean, School of Medicine University of New Columbia Washington, DC (Medicine) Secretary: Edwin Booth, PhD Associate Dean for Curriculum University of Baltimore School of Medicine Baltimore, MD Member: Stephen Douglas, MD, PhD Associate Dean for Student Affairs Appleby School of Medicine Cupertino, California (Anatomy) (Psychiatry) The survey team then develops a paragraph expressing its appreciation to various individuals at the school. Feel free to modify the language in the paragraph in the report template. SUMMARY OF SURVEY TEAM FINDINGS Include the disclaimer, as in the survey report template. DISCLAIMER: The summary that follows represent the findings of the ad hoc survey team that visited [school name] from [visit dates], based on the information provided by the school and its representatives before and during the accreditation survey, and by the LCME. The LCME may come to differing conclusions when it reviews the team s report and any related information. Summarize the survey team's findings for each element reviewed during the survey under the appropriate standard, as contained in Functions and Structure of a Medical School (March 2014), which can be accessed from the LCME website at: Do not include standards where there are no elements under review. Under the remaining standards, the team s findings should be organized as: Areas that are Satisfactory Areas in that are Satisfactory a Need for Monitoring Areas that are Unsatisfactory

8 LCME Survey Report Guide for Limited Accreditation Surveys, Page 5 Note that there may not be findings under each of these headings. Delete the headings where there are no findings. Standard 1: Mission, Planning, Organization, and Integrity Areas that are Satisfactory Element Number: Quotation of the element Finding: Provide a summary of evidence that the element is satisfactory. Areas that are Satisfactory with a Need for Monitoring Element Number: Quotation of the element Finding: Provide a summary of evidence that performance appears to be satisfactory but that ongoing monitoring is required. Areas of that are Unsatisfactory Element Number: Quotation of the element Finding: Provide a summary of evidence that performance is unsatisfactory This same format for reporting findings is repeated for the other standards where one or more elements were reviewed by the survey team. LCME FINDINGS FROM THE PREVIOUS FULL SURVEY Include the dashboard that was provided with the team mailing to briefly summarize the accreditation history since the time of the previous full survey. If the full survey occurred before the transition to standards/elements (i.e., prior to July 1, 2015), include the standard number and short title of the standard and the LCME finding for each standard that was either in compliance with a need for monitoring or in noncompliance at the time of the full survey (or the other event that served as a trigger for this limited survey). Also cross-reference the old standard to the new element, as illustrated below and in the survey report template. Note that Functions and Structure of a Medical School (March 2014) contains a crossreference of the old standards with the new standards/elements. Areas in Compliance with a Need for Monitoring: Standard Number from previous full survey (short title): IS-11 (Administrative Structure) Element Number (short title): 2.4 (Sufficiency of Administrative Staff) Finding: There had been considerable turnover at various levels of institutional leadership, including the deanship and a number of departmental chairs. At the time of the full survey visit, a new dean and two department chairs had recently taken office and recruitments were underway for two additional department chairs

9 LCME Survey Report Guide for Limited Accreditation Surveys, Page 6 Continue with all the findings from the previous full survey visit that the LCME found to be in compliance with a need for monitoring. Areas in Noncompliance: Standard Number (short title): IS-16 (Diversity) Element Number (short title): 3.3 (Diversity/Pipeline Programs and Partnerships) Finding: The medical education program had not clearly or consistently characterized diversity for the institution or clearly articulated its diversity goals for those groups, with the result that it had not yet achieved significant diversity among its students, faculty, and staff relative to its mission. Continue with all the findings from the previous full survey visit that were found to be in noncompliance. THE BRIEFING BOOK Provide a discussion of whether the briefing book was clear and complete and addressed the issues identified by the LCME, as for a full survey visit. BRIEF HISTORY AND SETTING OF THE SCHOOL This section should contain enough relevant information about the history and setting of the school to serve as a frame of reference for LCME review of and consideration of the survey report. SURVEY TEAM FINDINGS AND RECOMMENDATIONS [Only include standards for which there are elements that were reviewed during the survey visit] STANDARD 1: MISSION, PLANNING, ORGANIZATION, AND INTEGRITY See Appendix for the following documents: Element Number (Title) Detailed discussion of findings. Team s Recommendation on status of the element: Element Number (Title) Detailed discussion of findings. Team s Recommendation on status of the element:

10 LCME Survey Report Guide for Limited Accreditation Surveys, Page 7 STANDARD 2: LEADERSHIP AND ADMINISTRATION See Appendix for the following documents: Element Number (Title) Detailed discussion of findings. Team s Recommendation on status of the element: Element Number (Title) Detailed discussion of findings. Team s Recommendation on status of the element: [Continue, including only those standards where there were elements that were reviewed by the survey team]

11 LCME Survey Report Guide for Limited Accreditation Surveys, Page 8 STYLE GUIDE FOR REPORT PREPARATION Each team member should edit his or her section(s) carefully before submitting it to the team secretary. The survey team secretary should edit the total report for clarity and consistency, as well as for spelling and formatting. 1. Use one-inch margins throughout since the pages will be printed front and back by the LCME office. 2. Use the font of the template supplied by the Secretariat (11-point, Times New Roman). 3. Carefully check the quality of all images, tables, and scanned copies. Scanners may produce distortions, low contrast, or crooked pages. Be sure that originals are of high resolution for quality reproduction. Do not include color. 4. After the entire report has been completed and assembled, put page numbers in the bottom center of each page, including appendices. Number the pages of the report consecutively. Do not number each section separately. 5. Place the Table of Contents (including that for the appendix) immediately after the title page. These pages should be numbered in lowercase Roman numerals in the bottom center of the page (as in the survey report template). 6. Please use common style conventions: The word "dean" is not capitalized except when it begins a sentence or includes the name of the individual - "Dean Robert Jones." The same is true for vice president, provost, president, and chair. The words "medical school," "college," and "university" are not capitalized unless they begin sentences or are used as the school s full name (such as Jones Medical School). The word "faculty" is not capitalized unless it begins a sentence or is the Canadian equivalent of school, e.g., "The president intends to allocate more funds to the Jones Faculty of Medicine for laboratory construction." Discipline names (e.g., "Physiology," "Biochemistry," "Medicine,") are capitalized when they refer to departments. Note that "department" is not capitalized unless it is used with reference to a specific discipline, as in "Department of Medicine." Capitalize the names of formal school committees and subcommittees (e.g., Committee on Educational Policy), but do not capitalize the committee if the formal name is not used and the committee is referred to just by function (e.g., curriculum committee). 7. The covering memorandum from the team secretary follows the appendices and should be numbered as page Before submitting the draft report to the LCME Secretariat, carefully proofread the draft report to correct spelling, typographical, grammatical, and punctuation errors. 9. The team secretary should follow the instructions for the review of the draft report, as described in this document (pages 1-2).

12 LCME Survey Report Guide for Limited Accreditation Surveys, Page The team secretary should sign the cover memo before submitting the final copy. An electronic signature is appropriate. 11. A clean copy of the final report, including both the narrative and the appendix, should be submitted electronically to the LCME Secretariat using the LCME Secure Electronic File transfer tool, accessible at < The team secretary will be sent information about access to the file transfer tool, which will accept large files. The file submission may include two files: the narrative portion as a Word document and the appendix as a single PDF file. The narrative and appendix also may be submitted as a single Word document. Copies of all correspondence between the dean and the team secretary regarding changes to the report should be included separately with the final report submission. Please expect to receive an confirming successful submission the next business day. If you do not receive confirmation or need assistance, please phone