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2021-22 Limited Survey Visit Preparation

Overview

As outlined in Rules of Procedure, limited surveys are on-site evaluations conducted by ad hoc survey teams to evaluate a medical education program in instances when the program was previously found to be in noncompliance/unsatisfactory performance or to be in compliance/satisfactory performance with a need for monitoring with identified standards/elements.

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 Limited Survey Visit Preparation, is intended to help schools navigate the various stages of the limited survey visit process. Below are short descriptions of what can be found in each tab.

If any questions arise, contact the LCME Secretariat staff.

Getting Started

  • Establish the survey visit date
  • Review the survey personnel (faculty accreditation lead and survey visit coordinator)

Action Plan

  • What the action plan is and how is it used prior to the limited survey visit

Timeline

  • A detailed timeline of responsibilities and activities leading up to and after the survey visit

Completing the Briefing Book

  • What is the Briefing book
  • Data that may be requested (LCME Part 1-A, 1-B, Part II, AAMC GQ, and Prepopulated LCME Data Tables Report)

Submitting the Briefing Book

  • Briefing book contents and due date
  • Using the SEFT to submit the briefing book

Submitting Updates

  • Types of 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

Getting Started

Details on the steps in a limited accreditation review can be found in the Guidelines for the Planning and Conduct of Accreditation Survey Visits on the publications page.

Establish the Survey Visit Date

The dean will be made aware of the LCME’s decision to conduct a limited survey in the initial letter of accreditation that conveyed the school’s accreditation status (e.g., accredited, undetermined term; accredited, on warning; accredited, on probation) and the request for an action plan (see Action Plan). At the time of initial notification of the school’s accreditation status, well before the visit date is set, the school should begin addressing the LCME’s concerns. Through developing the action plan, the school will identify the steps that need to be taken for each area needing attention.

The LCME Secretariat will provide the program with instructions regarding the documentation required for the limited survey approximately six months prior to the visit. The timeframe for emergent situations may be shorter.

Review Survey Personnel

Once the limited survey is confirmed, the dean should review the designated faculty accreditation lead (FAL) and a survey visit coordinator (SVC) that was identified for the previous full survey visit. 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 VisitsIf any changes are needed the dean should notify the LCME via email to lcme@aamc.org.

Action Plan

Prior to setting a date for a limited survey visit, the LCME will ask the school to submit an action plan describing the way in which the school will address the issues and concerns previously identified by the LCME. Specific instructions for the action plan will be included with the LCME’s initial letter of accreditation. The LCME will direct the LCME Secretariat to arrange an on-site consultation with the school to assist with the development of the action plan. The action plan should include each of the following sections:

  1. Brief introduction (generally, a cover letter from the dean)
  2. Narrative summary of the overall strategy to address each element where there is unsatisfactory performance and each where performance is satisfactory with a need for monitoring
  3. Table outlining the specific steps that have been or will be taken for each element, along with the individual(s)/group(s) responsible, the anticipated date when the action will be completed, and the indicator(s) that will be used to determine whether the issue has been successfully resolved (this can refer to the narrative summary)
  4. Appendix (if necessary)

The LCME will review the action plan and, if the plan is accepted by the LCME, instruct the LCME Secretariat to set a date for the limited survey visit. After approval by the LCME, the action plan is for the use of the school and will not be provided to the team conducting the limited survey.

An action plan should include a dated and signed cover letter from the dean that is addressed to both LCME Co-Secretaries. These documents should be submitted via email to lcmesubmissions@aamc.org as a single PDF on or prior to the submission date conveyed in the letter of accreditation from the LCME.

Timeline

Approximately six months before the limited survey visit, the LCME Secretariat will send the dean a letter with detailed instructions for constructing a briefing book for the visit. The briefing book will include a review of each element requiring follow-up (i.e., each element for which the LCME determined that the school’s performance was either unsatisfactory or satisfactory with a need for monitoring).

The briefing book should be submitted to the LCME Secretariat at least six weeks before the visit. The LCME Secretariat staff will provide a username, password, and instructions on how to submit the briefing book, via Secure Electronic File Transfer (SEFT), approximately four weeks before the briefing book is due. Guidelines for submission are in subsequent tabs on this webpage. It is very important that the school maintain this timeline so that the briefing book will be completed on schedule. Questions about submission should be sent to LCME staff via email to lcmesubmissions@aamc.org.

Approximately three months before the visit, the LCME Secretariat will send the dean the names of the limited survey team members. If the dean believes that any team member presents a potential conflict of interest regarding participation in the survey visit, he or she should immediately notify the LCME Secretariat.

Completing the Briefing Book

The faculty accreditation lead (FAL) should assign responsibility for each element requiring follow-up to the most knowledgeable individual(s). The narrative portion of the briefing book should be organized by standard and element, starting with elements that were identified as unsatisfactory and then elements that were identified as satisfactory with a need for monitoring. Appendix documents should be placed at the end of the briefing book, organized by standard/element as in the narrative portion. The narrative for an element should refer to any appendix document(s).

When the briefing book has been assembled, it should be reviewed by the FAL or similar knowledgeable individual(s) to ensure that it is complete and clear.

Data

Depending on what is requested in the briefing book, a school may need to consider data from annual questionnaires administered by the AAMC and AMA. If relevant, 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.

Data Source Timeline Contact Information
LCME Part I-A
Annual Financial Questionnaire (AFQ) and Overview of Organization and Financial Characteristics Survey
  • Made available to schools for completion in mid-September.
  • Due to the AAMC in mid-December.
  • Online report published in mid-June.
Questions should be emailed to afq@aamc.org
LCME Part I-B
Student Financial Aid Questionnaire
  • Made available to schools for completion in July.
  • Due to the AAMC in September.
  • Online report published in May.
Questions should be emailed to  lcmeib@aamc.org
LCME Part II Annual Medical School Questionnaire
  • Made available to schools for completion in February.
  • Due to the AMA in April.
  • Report published in September edition of JAMA.

Sylvia Etzel
Research Associate
AMA Department of Data Acquisition Services
Email: sylvia.etzel@ama-assn.org
Phone: 312-464-4693

AAMC Medical School Graduation Questionnaire (AAMC GQ)
  • Made available to students for completion in February.
  • Results are available to schools in August.

Questions should be emailed to gq@aamc.org

Prepopulated LCME Data Tables Report
  • Made available to medical school deans in March.

Questions should be emailed to lcmedatatables@aamc.org

Submitting the Briefing Book

Unlike other types of survey visits, there is no “survey package” for a limited survey visit. Instead, a school undergoing a limited survey visit prepares a customized “briefing book” with information on each element for which the LCME determined that the school’s performance was either unsatisfactory or satisfactory with a need for monitoring.

Approximately six months before the survey visit, the LCME Co-Secretaries will provide detailed instructions for constructing a briefing book for the visit. The briefing book will be due to the Secretariat six weeks prior to the first day of the scheduled survey visit. If the submission date falls on a weekend or holiday, the briefing book can be submitted the next non-holiday business day.

Using the SEFT to Submit the Survey Package

Schools will submit the briefing book via the Secure Electronic File Transfer (SEFT) system. system. The dean and designated faculty accreditation lead (FAL) will receive an email from LCME Secretariat staff four weeks before the briefing book is due with SEFT account access and instructions for uploading files.

After the Briefing Book Has Been Submitted

Once all contents of the completed briefing book have been uploaded on SEFT, the school should email lcmesubmissions@aamc.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 briefing book.

A limited survey visit typically does not require updates to the briefing book, however, in the event that updates are needed or requested, follow instructions on the Submitting Updates tab.

Questions?

Questions about briefing book content and deadlines should be directed to lcme@aamc.org. Questions about formatting and submission should be directed to lcme@aamc.org.

Submitting Updates

A limited survey visit typically does not require updates to the briefing book; however, updates to the briefing book may be provided by the school at the request of the survey team. Note that updates that are not requested by the survey team (“unsolicited updates”) will not be accepted. In the event that updates are requested, the school’s faculty accreditation lead (FAL) should confirm with the survey team secretary to determine his or her preference regarding how any updates should be transmitted to the team. Information requested by the survey team may be provided until the close of the visit.

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.

On-site 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

The limited survey team will prepare a draft report using the Survey Report Template for Limited Survey Visit Reports. The survey team secretary should use the Survey Team Findings for Limited Survey Visit Reports template to record the team’s findings of elements with which the school’s performance has been evaluated as unsatisfactory or satisfactory with a need for monitoring. Ideally, the draft report should be completed by the survey team secretary with input from survey team members within six to eight weeks following the conclusion of the survey visit.

The draft survey report and associated team findings document will undergo several sequential reviews before it is submitted to the LCME for action.

  • 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. Any corrections suggested by the dean must reference information that was included in the school’s briefing book or provided to the team during the survey visit. Events or actions originating after the survey visit or documents (e.g., copies of policies) available at the time of the survey visit, but not provided to the team, will not be considered in mitigation of findings identified in the survey 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, if any, of the changes recommended by the dean have been made in the final report and which recommended changes have not been made.

The final report is then submitted to the LCME Secretariat and considered at the next regularly scheduled meeting of the LCME, contingent upon the report being finalized and submitted with adequate time for the LCME to review the materials prior to the LCME meeting. The LCME typically meets early in October, February, and June.

The dean’s comments about the limited survey report and the response of the team secretary about the changes recommended by the dean that were or were not made in the final report are retained in the files of the LCME. Neither the dean’s letter nor the team secretary’s response will be shared with the LCME.

If the dean has remaining concerns about the process of the visit, he or she may write a letter to the LCME detailing these concerns. The dean’s letter must be provided to the LCME Secretariat within 10 business days of the time that he or she was informed by the team secretary of the changes made or not made to the survey report. No new information may be provided in the dean’s letter to the LCME and no attachments to the letter will be accepted.

Notification of LCME Action

LCME members will review the limited survey report and the survey team findings document at a regularly scheduled LCME meeting. LCME members will determine whether the medical education program’s performance in the accreditation elements that have been reviewed is satisfactory, satisfactory with a need for monitoring, or unsatisfactory. LCME members will also determine whether the program is in compliance, in compliance with a need for monitoring, or in noncompliance with relevant accreditation standards. The LCME also will determine an accreditation status for the medical school and any required follow-up.

The LCME Secretariat will communicate the LCME’s action to the president/chief executive officer of the institution sponsoring the medical education program within 30 days, with a copy of the letter of accreditation to the dean. The school’s accreditation status will be updated on the LCME website, along with the date of the next survey visit.

The LCME letter of accreditation will describe any required follow-up activities on the part of the school (e.g., provision of a status report). The LCME might also direct the LCME Secretariat to conduct a consultation visit to assist school personnel in understanding the LCME’s expectations for compliance with accreditation standards.