Editor’s Note: The UNMC College of Medicine is currently in the process of seeking reaccreditation through the Liaison Committee on Medical Education (LCME). The LCME site visit is scheduled for Oct. 6-9, 2013. During the accreditation process, Hugh Stoddard, Ph.D., director and special assistant dean for medical education, will provide a monthly update on accreditation. Dr. Stoddard is self-study coordinator for the College of Medicine. Here is this month’s item:
Question of the Month:
People refer to “getting dinged” by the LCME. What does that mean? What are the consequences of getting dinged by the LCME?
After reviewing our submitted documents (August issue of InterCOM) and the site visitors’ report, the LCME will make a determination on each of the 129 standards. Our program is assigned one of three categories for each standard. The categories used are:
In Compliance
The required policy, process, resource, or system is in place and, if required by the standard, there is evidence to indicate that it is effective.
In Compliance, with Monitoring
- 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. OR
- The medical education program is currently in compliance with the standard, but known circumstances exist that could lead to future noncompliance (formerly area in transition).
- In short, the school has identified a problem and a possible solution; however, no data yet exist about the efficacy of that solution.
Non-Compliance
The medical education program has not met one or more of the requirements of the standard. The required policy, process, resource, or system either is not in place or is in place, but has been found to be ineffective. In other words, the LCME believes there is a serious or persistent problem for which the school has not found a viable solution.
“Getting dinged” is a long-standing colloquial expression for a finding of Non-Compliance. The new category of In Compliance, with Monitoring was created in 2011 as a means of indicating that the LCME has concern about an issue but without the possibly severe consequences of a Non-Compliance finding.
Any standard for which a school is In Compliance, with Monitoring will entail the school re-evaluating the standard and submitting an interim progress report prior to the next full accreditation visit. We should consider any finding of In Compliance, with Monitoring, as well as Non-Compliance, as a ‘ding.’
In making its determination of accreditation, the LCME weighs the number and severity of standards for which a school has been found to be Non-Compliant and In Compliance, with Monitoring. There is no threshold number of ‘dings’ leading to action by the LCME. Some standards refer to aspects which are more crucial to the program than others, thus non-compliance with these leads to more serious consequences.
The LCME then votes on one of the following actions:
- Grant an accreditation status (typically for 8 years).
- Continue an accreditation status, with or without specifying the term of accreditation.
- Continue accreditation, but place the program on warning.
- Continue accreditation, but place the program on probation.
- Deny accreditation.
- Withdraw accreditation.
Although most programs are granted full re-accreditation, in recent years there have been a record number of programs placed on probation (4 programs out of 138, as of this writing). Serious consequences to a program that have resulted from the accreditation process are still rare, but are possible.
Our task over the next 14 months is to generate evidence that the LCME will use to verify our many accomplishments and address our rare deficiencies.