2021-22 Full Survey Visit Preparation
- Getting Started
- Completing the DCI
- Self-study Process
- Submitting the Survey Package
- Submitting Updates
- Hosting the Survey Visit
- Survey Report Review
- Notification of LCME Action
As outlined in Rules of Procedure, accreditation is a process by which institutions and programs voluntarily undergo an extensive peer-based evaluation of their compliance with accepted standards for educational quality. Through accreditation, the LCME provides assurance to medical students and graduates, the medical profession, healthcare institutions, and the public that:
- Educational programs culminating in the award of the MD degree meet reasonable, generally-accepted, and appropriate national standards for educational quality and
- Graduates of such programs have a complete and valid educational experience sufficient to prepare them for the next stage of their training.
Typically, medical education programs are reviewed every eight years. There are some exceptions described in Rules of Procedure, such as schools that move from provisional to full accreditation must have a full review five years after the initial award of full accreditation, or schools that have a review (status report, limited survey visit, etc.) that are deemed needing a full survey earlier or later than the eight year term based on findings from that review.
Beginning in March 2020, LCME accreditation survey visits and consultations moved to a virtual format due to the COVID-19 pandemic. Survey visits for full and provisional accreditation and limited visits will be virtual until further notice. Additional LCME accreditation resources and information related to COVID-19 is available on the COVID-19 Updates and Resources page.
Refer to Guidelines for the Planning and Conduct of Accreditation Survey Visits for more details on virtual visits.
This section of lcme.org, Accreditation Prep for 2021-22 Full Survey Visit Preparation, is intended to help schools navigate the various stages of the full survey visit process. Below are short descriptions of what can be found in each tab.
If any questions arise, contact the LCME Secretariat staff.
- Recommend a faculty fellow
- Designate survey personnel (faculty accreditation lead and survey visit coordinator)
- Establish the survey visit date
- Appoint self-study task force
- Hold an optional self-study kick-off event
- Attend LCME webinars and the Survey Prep Workshop
- A detailed timeline of responsibilities and activities leading up to and after the survey visit
Completing the DCI
- What is the DCI
- When is the DCI available and where is it located
- Information about common data sources (LCME Part 1-A, 1-B, Part II, AAMC GQ, and Prepopulated LCME Data Tables Report)
- What is the self-study
- Overview of process and organization of the self-study, including the task force
Submitting the Survey Package
- Survey package contents and due date
- Using the SEFT to submit the survey package
- Formatting documents, file names, and the DCI appendix
- Types of updates (including common data updates) and how to submit them
Hosting the Survey Visit
- Instructions on preparing for the survey visit and what to expect
- Details on hotel, transportation, meals, and what to prepare for the team
Survey Report Review
- Timeline and process for the survey report and team findings document
- When and how to submit feedback to the survey team during and after the survey report and team findings document are written
Notification of LCME Action
- How final accreditation decisions are made and what to expect
Recommend a Faculty Fellow
Three years prior to the survey visit, the LCME Secretariat invites the dean to recommend an experienced faculty member to serve as a faculty fellow. The fellow will be assigned as a survey team member on a full survey visit about two years before the fellow’s home institution’s full visit is scheduled. More information about the faculty fellow can be found in the Guidelines for the Planning and Conduct of Accreditation Survey Visits.
Designate Survey Personnel
Two years prior to the survey visit, the dean will be notified to designate a faculty accreditation lead (FAL) and survey visit coordinator (SVC) using the LCME Survey Personnel Designation Form. It is critical that both positions be staffed by individuals who have a deep understanding of the program and who will be able to work with stakeholders across the medical school, university, and affiliated hospitals and other health care settings. More information about the FAL and SVC can be found in the Guidelines for the Planning and Conduct of Accreditation Survey Visits and the Guide to the Institutional Self-study for Full Accreditation.
Establish the Survey Visit Date
The LCME Secretariat will contact the dean 18 months before the anticipated date of the next accreditation survey to establish specific dates. Typically, the date of the full survey visit falls within the same month as the previous full survey. More information about scheduling the survey visit can be found in Rules of Procedure.
Appoint Self-Study Task Force
The dean appoints members of the institutional self-study task force who are responsible for conducting the self-study. For details on the process refer to the Guide to the Institutional Self-study for Full Accreditation.
Hold an Optional Self-study Kick-off Event
As the medical school prepares to begin its self-study, it can choose to hold a “self-study kick-off” workshop involving the faculty and staff who will need to be engaged during the accreditation review process. Members of the LCME Secretariat can participate in these workshops in order to provide a general overview of the process, focus on areas of concern from previous visits, and take questions from the various self-study groups. Secretariat availability is based on timing, and schools are encouraged to contact the LCME Secretariat early in the process to ensure that an LCME Secretariat staff member can attend. Requests should be sent to firstname.lastname@example.org.
Attend LCME Webinars and the Survey Prep Workshop
The LCME Secretariat offers the below sessions for schools preparing for survey visits. Designated survey personnel will automatically receive invitations to these events and are encouraged to attend.
- LCME Connecting with the Secretariat Webinars: January through October, the LCME Secretariat offers monthly Connecting with the Secretariat webinars that provide general information about accreditation and the self-study process and give participants an opportunity to discuss specific issues with members of the Secretariat. For details and registration information, visit the Connecting with the Secretariat webinar page.
- LCME Survey Prep Workshop: Approximately 18 months prior to the school’s full survey visit, the LCME Secretariat hosts a one-day, in-person Survey Prep Workshop that provides information about self-study preparation, survey visit logistics, the independent student analysis (ISA), and LCME standards and elements. For details and registration information, visit the Survey Prep Workshop page.
Full Survey Timeline
|Months +/- Survey Visit||Responsible Individuals/Groups||Activities|
|-18||LCME Secretariat and Dean||
|-18||FAL and SVC||
|-16||ISA Task Force||
|-15||ISA Task Force||
|-13||ISA Task Force||
|-12/-8||Self-study Task Force||
|-9||ISA Task Force||
|-8/-5||Self-study Task Force||
|-4||FAL and Dean||
|-3||FAL and Dean||
|-2.5/-2||Survey Team Secretary (for on-site visits)||
|-1.5/-1||Survey Team Secretary||
|-1||Survey Team Secretary||
|-.5||Survey Team Secretary and Survey Team||
|Survey Visit||Survey Team Chair/Secretary||
|Survey Visit||Survey Team Members||
|+1.5/+2||Survey Team Secretary|
|+2/+2.5||Survey Team Secretary||
|Within 30 days of LCME meeting||LCME Secretariat||
|+1.5 months following LCME meeting||LCME Secretariat||
Completing the Data Collection Instrument (DCI)
The DCI is a Word document that contains questions related to each element. Some of the questions ask for narrative explanations and some ask that tables be completed.
The DCI is posted on the LCME publications page approximately 15 months before the start of the academic year in which the survey will occur. The faculty accreditation lead (FAL) should determine which individuals at the school can supply the requested quantitative and narrative information.
Once the sections have been drafted, reviewed, and finalized, one staff member [e.g., the survey visit coordinator (SVC)] should be responsible for combining the information into one DCI (Word) document.
The FAL should review the combined material to ensure that the information has been added accurately, the formatting has been preserved, and that the DCI is complete, clear, and consistent across all sections.
More details on the DCI process can be found in the Guide to the Institutional Self-study for Full Accreditation.
Style Guide for the DCI
A Style Guide for DCI Preparation can be found on the publications page. Programs should use this when completing the DCI.
Common Data Sources
Much of the quantitative data requested in the DCI can be obtained from annual questionnaires administered by the AAMC and AMA. U.S. schools may use data from the Part I-A Annual Financial Questionnaire, the Part I-B Student Financial Aid Questionnaire, and the Part II Annual Medical School Questionnaire, as well as the AAMC Medical School Profile System (MSPS) and the Longitudinal Statistical Summary Report (LSSR).
Schools should contact the appropriate data administrator with questions or corrections to the following documents.
Note that if a school is preparing for its first full accreditation survey, it may not have graduating students so data from the AAMC Medical School Graduation Questionnaire does not need to be submitted to the LCME.
|Data Source||Timeline||Contact Information|
|LCME Part I-A
Annual Financial Questionnaire (AFQ) and Overview of Organization and Financial Characteristics Survey
||Questions should be emailed to email@example.com|
|LCME Part I-B
Student Financial Aid Questionnaire
||Questions should be emailed to firstname.lastname@example.org|
|LCME Part II Annual Medical School Questionnaire||
|AAMC Medical School Graduation Questionnaire (AAMC GQ)||
Questions should be emailed to email@example.com
|Prepopulated LCME Data Tables Report||
Questions should be emailed to firstname.lastname@example.org
The school’s self-study allows it to make its own determinations of areas that are working well and those that require attention, using the LCME accreditation standards and elements as a guide.
This section is a brief overview of the self-study. Refer to the Guide to the Development of the Institutional Self-study Summary Report for Full Accreditation for detailed information about organizing and conducting the self-study.
Self-study Task Force
- Has ultimate responsibility for designing the self-study process
- Prepares the final self-study summary report
- Determines the objectives of the self-study process
- Sets the timetable for the completion of all related activities
- Finalizes and approves the self-study summary report
- Chaired by the dean or other senior leader of the medical school and coordinated by the faculty accreditation lead (FAL)
- FAL and the self-study task force review the DCI and related documents to identify institutional strengths/challenges related to performance in elements and to develop strategies to address performance gaps
- There should be broad participation in the self-study process involving the different stakeholder groups at the institution, including members of the faculty and administration and medical students, as well as representatives of the sponsoring institution and of the medical school’s clinical affiliates.
- There should be broad participation in the self-study task force involving the different stakeholder groups at the institution, including members of the faculty and administration and medical students, as well as representatives of the sponsoring institution and of the medical school’s clinical affiliates.
- Should have access to the relevant portions of the DCI and related documents (AAMC Medical School Graduation Questionnaire and the independent student analysis, etc.)
- FAL should assist the task force members in identifying additional relevant data sources, as appropriate.
Self-study Summary Report
- Should begin with a brief introduction describing how the self-study process was conducted and include the membership categories of self-study task force members (with a reference to the complete list of task force members in the Appendix).
- Include a brief explanation related to the effects of the COVID-19 pandemic summarized from what was included in the DCI. For relevant elements related to the curriculum, student services, facilities, finances, and other areas that might have been affected by the COVID-19 pandemic, incorporate pre-COVID, during COVID, and post-COVID context in interpreting data to judge the school’s performance in the accreditation elements. Include these considerations in your evaluation and interpretation of student satisfaction data from the ISA and the AAMC Medical School Graduation Questionnaire.
- Should be organized into sections of institutional strengths, challenges/areas of concern related to performance in accreditation elements, and specific activities undertaken or planned to address each of the challenges/areas of concern. The concerns may reference a single element or group of related elements (e.g., elements related to curriculum management).
- If the self-study summary report was written by a subset of the task force, the full task force should review it and must affirm that they agree with its conclusions.Should be written in Times New Roman, black, and size 11 font, single-spaced, and should include approximately five to eight pages of single-spaced narrative, excluding the list of task force members contained in the report Appendix.
Submitting the Survey Package
Survey Package Contents and Due Date
A complete survey package for a full survey visit consists of the following:
- Completed data collection instrument (DCI)
- DCI Appendix (the supporting documents for each section of the DCI)
- Self-study summary report
- Independent student analysis (ISA)
- AAMC Medical School Graduation Questionnaire (AAMC GQ) Individual School Report
The complete survey package should be submitted 12 weeks prior to the first day of the scheduled survey visit. If the submission date falls on a weekend or holiday, the survey package can be submitted the next non-holiday business day.
Using the SEFT to Submit the Survey Package
Schools will submit the survey package via the Secure Electronic File Transfer (SEFT) system. The dean and designated faculty accreditation lead (FAL) will receive an email from LCME Secretariat staff four weeks before the survey package is due with SEFT account access and instructions for uploading files.
The SEFT account will be preloaded with the following empty folders:
When the school is ready to submit the survey package to the LCME, the contents should be uploaded into the appropriate five folders (as indicated in the screenshot above). For example, the final DCI Word document will be uploaded into the folder on SEFT titled “1-DCI”, the final appendix documents in “2-DCI Appendix”, the final self-study summary report in “3-Self-study report”, and so on.
The school will not have the ability to edit or delete files in SEFT. If an error has occurred and a file needs to be deleted, contact LCME staff at email@example.com or call (202)-828-0596.
Formatting Documents in the Survey Package
The documents that make up a complete survey package should be formatted using the below guidelines:
- 1-DCI – Word document, Times New Roman, 11-pt, single spaced (All 12 Standards should be saved as one document. Do not submit the Standard sections as separate documents.)
- 2-DCI Appendix – Word documents are preferred, but if the original file is PDF, Excel, or PowerPoint, it is acceptable and should not be altered
- 3-Self-study report – Word document, Times New Roman, 11-pt, single spaced
- 4-ISA – Word document, Times New Roman, 11-pt, single spaced (A Word document is preferred, but if PDF is the only available file type, the school should make sure that it is easy to navigate and copy and paste content into a Word document.)
- 5-AAMC GQ – PDF file
- File names should stay under 30 characters. If file names are longer than 30 characters, LCME Secretariat staff may contact the school to shorten file names and resubmit the complete survey package.
- If PDF files are included, the PDF should not be a scan of an original document, as images do not allow copy/paste and survey team members will need that feature to create the survey report.
The most important principle to keep in mind when building the DCI appendix is that the files be as easy as possible for the survey team members to find information. Below are some tips to make the appendix follow a structure that the team members can follow.
The “2-DCI Appendix” folder should house all of the supporting documentation for the DCI. It is preferred to have all of the individual files within the root of the folder and not to have folders by Standard and/or Element. The SEFT system does not allow multiple files to be uploaded together so it is advised that all of the files be zipped and uploaded once.
File Naming Convention
The file names should be under 30 characters and should include the standard and element they relate to and a short description that helps the survey team members identify what they are looking for. For example, a Word document of a campus map that relates to Standard 1, Element 1 should be titled “1-01 Campus Map”, a PDF of a dean’s organization chart for Standard 2, Element 3 should be titled “2-03 Dean Org Chart”, etc. Please do not include the school name in file names. An example of the file naming convention is also below.
- 2-DCI Appendix
- _Table of Contents.doc
- 1-01 Exec Sum Strategic Plan.doc
- 1-02 Standing Committee.xls
- 2-02 Dean Position Description.doc
- 2-02 Dean Resume.pdf
Table of Contents
The “2-DCI Appendix” folder should also include a Word document table of contents to help the survey team navigate all of the files. The document should be titled, “_Table of Contents”. Note that when files are uploaded into the “2-DCI Appendix” folder, they will appear numerically. Adding an underscore before the table of contents title will ensure the file shows at the top of the list of appendix files.
If there is a request for the school to provide a copy of specific documents, the school should save an electronic copy of the document in the “2-DCI Appendix” folder.
Within the DCI, if there is a request for the school to provide a copy of specific policies, the school should save an electronic copy of the policy in the “2-DCI Appendix” folder provided. If the policy is a segment of a larger document, to the school should provide only an electronic copy of the pertinent pages of the document in the “2-DCI Appendix” folder.
After the Survey Package Has Been Submitted
Once all contents of the completed survey package have been uploaded on SEFT, the school should email firstname.lastname@example.org to notify LCME staff and request a confirmation that the files have been uploaded successfully. For example:
The LCME Secretariat staff will ensure that each survey team member receives the school’s submitted survey package.
Schools are responsible for submitting updates to the survey package (see Submitting Updates tab).
Typically, there are three types of required updates after the survey package has been submitted: (1) missing and incomplete information; (2) institutional changes, new data, and/or corrections; and (3) supplemental information. Details of what, how, and when to submit updates are described below.
Types of Updates
1) Missing and Incomplete Information: Approximately 4-6 weeks prior to the survey visit, LCME Secretariat staff conduct a brief review of the school’s submitted survey package focusing on items that are sometimes found to be missing or incomplete. LCME Secretariat staff contact the faculty accreditation lead (FAL) with instructions for submitting any such items. Typically, the instructions are to email the material to the LCME staff and to the survey team secretary.
2) Institutional Changes, New Data, and/or Corrections: Corrections to the initial survey package submission; newly released quantitative data; and major changes to the school’s curriculum, policies, finances, or governing structure (including changes implemented in order to correct an issue identified in the self-study) should be bundled into one of two monthly update batches and emailed to the survey team secretary. The first update batch should be sent two months prior to the survey visit; the second update batch should be sent one month prior to the survey visit. Provide an update summary with both updates. See the “Common Data Updates” section below for examples.
3) Supplemental Information: Survey team members may identify areas that require information not originally provided in the survey package submission. The team secretary will notify the FAL and provide instructions about the type of material(s) that should be submitted. This type of update should not be held for one of the monthly batch updates; it should be emailed to the team secretary as soon as it is requested.
Submitting Updates to the Survey Team
Updates or corrections made to the DCI after the survey package has been submitted should be bundled and sent to the team secretary. One bundled update may be sent to the survey team up to 30 calendar days prior to the start of the survey visit. Updates that are not requested by the survey team (“unsolicited updates”) must be submitted 30 calendar days before the start of the survey visit. While no unsolicited updates from the school can be accepted during the survey visit, survey team members may ask for additional information until the visit ends, as such, information requested by the survey team may be provided by the school until the close of the visit.
At the conclusion of the visit, all updates, including any updates or additional information provided to the survey team during the survey visit, should be compiled on a USB (thumb) drive and given to each team member. Include a “Table of Contents” listing the updates contained on the drive.
Submitting the End-of-Visit Update to the LCME Secretariat
Schools are also required to submit one end-of-visit update to the LCME Secretariat. That update should consist of all updates and other information provided to the survey team from the time of the initial survey package submission until the conclusion of the survey visit. At the conclusion of the final day of the survey visit, the complete batch of updates should be emailed to the LCME Secretariat at email@example.com. If the update is too large to be emailed, use the Secure Electronic File Transfer (SEFT) account from your original survey package submission. Email firstname.lastname@example.org if you need help. Note: the content of this update is identical to the content provided to each team member on a USB (thumb) drive on the final day of the survey visit.
Common Data Updates
|MCAT scores and GPAs of the most recent matriculating class||School||Standard 10|
|USMLE Steps 1, 2, and 3 pass rates and scores||National Board of Medical Examiners||Element 8.4|
|Admissions data||School||Standard 10|
|Most recent LCME Part I-A Annual Financial Questionnaire (AFQ) and Overview of Organization and Financial Characteristics document||LCME Part I-A AFQ and responses to the accompanying web-based companion survey to the LCME Part I-A “Overview of Organization and Financial Characteristics”||
|Mean graduating student indebtedness data||LCME Part I-B Student Financial Aid Questionnaire (available in May)||
|Most recent AAMC Medical School Graduation Questionnaire (AAMC GQ) Individual School Report||AAMC GQ (typically available in August)||Standard 1|
General Update Guidelines
- The overall goal when providing post-submission updates is to make the new information easy for the survey team to identify and integrate into the existing survey package.
- Survey team members often copy and paste relevant data from the survey package into the survey report. To facilitate this process, updated documents should be submitted in either Microsoft Word or in a PDF document that has been created directly from a Word document (i.e., it should be easy to copy and paste the information from the PDF document into a Word document).
- All updates should be tracked and recorded in an update summary document that provides a one or two sentence description of each update, along with the relevant sections and page number(s) that were affected by the update.
- When updating portions of the DCI, add the word “UPDATED” along with the submission date at the top of the relevant pages. Submit the updated pages, updating pagination as needed.
- Updates to narrative responses in the DCI should be made using “track changes” so that the original text is visible and the corrected text is in a red font. Updates to data tables should be made equally clear with highlighting or red text. Follow the same procedures when updating the appendix. In addition, be sure to update the table of contents. Only send updated pages, not the complete DCI.
Hosting the Survey Visit
Beginning in March 2020, LCME accreditation survey visits moved to a virtual format due to the COVID-19 pandemic. For virtual visits, the SVC coordinates with campus IT to ensure that the survey team and school participants can access the visit sessions. This should be discussed with the survey team secretary and information on how to log into the visit should be sent to the team prior to the visit. The SVC could schedule a practice run for the survey team (and for school participants, if desired) to ensure that all are familiar with the selected platform (e.g., Zoom) and comfortable with its use. It is helpful to have IT “on-call” during the visit to troubleshoot any problems. For efficiency during the visit, it is helpful to have a lead for each session, who coordinates which participant will answer specific team member questions.
Refer to Guidelines for the Planning and Conduct of Accreditation Survey Visits for more details on virtual visits.
Survey visits will be virtual until further notice. The listed responsibilities (i.e., hotel arrangements, ground transportation, meals, and survey team’s “home room” at the medical school) are not applicable at this time. Notice will be given in a timely manner about return to an on-site visit format so that visit preparations can proceed.
Survey Report Review
- At the conclusion of the survey visit, the survey team members will prepare a survey report and team findings document.
- Review by the LCME Secretariat: The survey team secretary will first send the report and findings to the LCME Secretariat, whose initial review will ensure that the findings are well documented, the report is internally consistent, and all elements have been addressed. The team secretary will revise the report based on this feedback.
- Review by the survey team: The survey team members will have five business days to review the draft report for clarity and completeness. The team secretary will address any team member’s suggested edits and/or comments.
- Review by the dean: The dean will have 10 business days to review the draft report. Following a careful review, the dean should send a written response to the team secretary in which he or she either confirms that the report accurately depicts the institution or notes any factual errors in the report.
- The team secretary, in consultation with the team chair, may revise the draft report based on issues raised in the dean’s response. The team secretary will notify the dean which recommended changes to the final survey report have been made and which have not been made.
- The final report is submitted to the LCME Secretariat and considered at a regularly scheduled meeting of the LCME. The LCME typically meets early in October, February, and June.
For more details, refer to the Guidelines for the Planning and Conduct of Accreditation Survey Visits and the Survey Report and Team Findings Guide.
Notification of LCME Action
- LCME members will review the final survey report and team findings document at a regularly scheduled LCME meeting.
- LCME members will determine whether the medical education program’s performance of accreditation elements is satisfactory, satisfactory with a need for monitoring, or unsatisfactory and whether the program is in compliance, in compliance with a need for monitoring, or in noncompliance with accreditation standards.
- The LCME will determine an accreditation status for the program and any required follow-up. For existing, fully accredited medical education programs, the LCME may take one of the following actions: continue accreditation for an eight-year term; continue accreditation for an undetermined term; continue accreditation, but place the program on warning; continue accreditation, but place the program on probation (this action is subject to reconsideration); or withdraw accreditation (this action is subject to appeal).
- The LCME Secretariat will communicate the LCME’s findings related to elements and accreditation standards and its accreditation action within 30 days to the president/chief executive officer of the institution sponsoring the medical education program, with a copy of the letter of accreditation to the dean. The school’s accreditation status along with the date of the next survey visit will be updated on the Directory page of lcme.org.
Details and further explanation of decisions and follow-up can be found in Rules of Procedure.