Frequently Asked Questions

The Paul L. Foster School of Medicine’s next full LCME accreditation survey site visit is scheduled for November 12-15, 2017. The survey team will arrive on Sunday in time for an initial early evening conference with the dean, and the team will depart by early afternoon on Wednesday.

Our final school survey package submission is due no later than August 21, 2017, 12 weeks prior to the survey visit.

The Liaison Committee on Medical Education (LCME) is the independent accrediting agency officially recognized by the U.S. Department of Education for allopathic medical schools in the U.S. and Canada. This organization is jointly sponsored by the AMA and AAMC but is an independent organization.

The LCME accreditation process is an opportunity to reflect on the newly formed medical education program and a way to take steps toward further improvement and continued innovation. LCME accreditation is also important as it signifies quality assurance of PLFSOM education practices and the resources available to support the Texas Tech University Health Sciences Center El Paso mission. Finally, it is important for the eligibility for PLFSOM students. Accreditation is required for federal grants, student financial aid, USMLE licensure exams and the ability for ACGME accredited residencies.

LCME accreditation is a process using a specific set of defined standards. Every eight years each institution must go through a self-assessment process called the “self-study” that incorporates these standards and a commitment to Continuous Quality Improvement (CQI). The process culminates with a peer review visit from an LCME Committee who evaluates PLFSOM programs based on the current LCME standards.

More specifically, the accreditation process consists of institutional self-assessment and peer review. Information provided by the medical school is considered by both the institution and survey team in the context of accreditation standards. The general steps in the process are as follows:

  1. Completion of the data collection instrument (DCI), the student survey and compilation of supporting documents.

    The associate dean for medical education distributed sections of the DCI (by standard, element, or questions) to those individuals best able to provide accurate and current information first in January 2016. Most individuals then completed and returned their sections of the DCI to the PLFSOM LCME accreditation team by April 30, 2016. Drafted elements are currently being reviewed to ensure the information is complete, accurate, and are returned, as needed, for revisions and updates. This process should be completed by July 31, 2016.
  1. Analysis of the DCI and other information sources, including the independent student analysis, its subcommittees, and development of self-study reports in each area.
  1. Survey Prep Executive Committee (SPEC) synthesizes the individual reports into an institutional self-study summary report.
  1. Visit by an ad hoc survey team and preparation of the survey team report for review by the LCME.
  1. Action on accreditation by the LCME.

LCME accreditation has 12 standards that are divided into 94 elements. The standards incorporate the requirement for institutional setting, education program, medical students, faculty and resources available. To learn more about the current LCME Standards and Elements visit lcme.org

The self-study is a massive coordinated effort through a number or organized committees and subcommittees with broad school representation. Using the LCME standards and elements as a framework, evidence is gathered to prepare a lengthy report of the state of our school; our strengths, are areas of improvement and our plans to continually meet our mission and objectives.

The Survey Prep Executive Committee (SPEC) and its subcommittees are responsible for conducting the self-study at the Paul L. Foster School of Medicine. This effort consists of bringing together representatives and stakeholders from administration, faculty, the student body, and other constituencies in order to:

  1. Collect and review data about the medical school and its educational program
  2. Identify both institutional strengths and challenges that require attention
  3. Define strategies to ensure that the strengths are maintained and any problems are addressed effectively

The LCME Committee, which includes 19 members chosen by the AAMC and the AMA, makes all accreditation decisions. This group consists of our peers and has representatives who are medical educators, administrators, practicing physicians and students.

When evaluating the accreditation status of a medical education programs leading to the MD degree the LCME may take the following actions:

  • Grant an accreditation status (full, provisional, or preliminary)
  • Continue an accreditation status, with or without specifying the term of accreditation
  • Continue an accreditation status, but place the program on warning
  • Continue an accreditation status, but place the program on probation
  • Deny an accreditation status
  • Withdraw accreditation

The LCME may also require one or more follow-up activities (e.g., limited survey visits, consultations, status reports) if it determines that the program is not in compliance with one or more accreditation standards or has unsatisfactory performance in one or more accreditation elements, or if the LCME has identified areas in compliance that require monitoring where the final outcome could result in noncompliance with one or more accreditation standards.

The Paul L. Foster School of Medicine did receive full LCME accreditation in February 2013. However, the 8 year cycle begins from the date of application for our provisional LCME accreditation. Once PLFSOM obtains its second full accreditation in good standing it should join the eight year cycle.

 

The ultimate responsibility for organizing the self-study and preparing the final self-study summary report rests with the Survey Prep Executive Committee (SPEC). This group determines the objectives of the self-study, sets the timetable for the completion of all related activities, and finalizes the summary self-study report.

SPEC synthesizes the individual subcommittee reports into a final self-study summary report (due at least 12 weeks prior to site visit). This entails the following steps:

  1. Looking across the subcommittee reports and the ISA to determine how individual components contribute to the ability of the program as a whole to achieve its aims and educate its students.
  2. The self-study document should be written in narrative form and organized as an answer to each specific item.
  3. Responses must be analytical and evaluative, not simply descriptive.
  4. Include a synthesis of major institutional strengths and challenges, including:
    1. Areas of potential unsatisfactory performance related to one or more elements.
    2. Any areas that may require monitoring due to changing circumstances.
    3. Challenges and issues of potential unsatisfactory performance related to elements or challenges that require attention.
    4. Recommendations for addressing any identified problems.
    5. Include a plan and timetable indicating how institutional strengths will be maintained and problems addressed.
  5. The final self-study summary report should:
    1. Be written in Times New Roman, black, and size 11 font.
    2. Not exceed 35 pages of single-spaced narrative, excluding the listing of subcommittee and task force members.
    3. Submitted as part of the survey package 12 weeks prior to the survey visit.
    4. Electronic copies of the individual subcommittee reports should be made available to the survey team, as requested, but should not be submitted with the survey package.

At least 12 weeks prior to the survey site visit the following documentation is sent to the LCME Survey Site Team:

  • Completed Data Collection Instrument (DCI)
  • Appendix of supporting documents for each DCI section
  • Self-study summary report
  • The Independent Student Analysis (ISA)
  • AAMC Graduation Questionnaire (AAMC GQ) Individual School Report