Print Friendly, PDF & Email

2021-22 Provisional Survey Visit Preparation

Overview

As outlined in Rules of Procedure, the purpose of provisional accreditation is to evaluate progress to date in the implementation of the medical education program and the status of planning for later stages of the program. After the program admits a charter class, it must complete the Data Collection Instrument (DCI) for Provisional Accreditation and conduct an independent student analysis (ISA) using a focused set of elements. No institutional self-study is required in the review for provisional accreditation.

There will not be an initial review of the DCI and the ISA by the LCME. All schools being reviewed for provisional accreditation will have a survey visit. The LCME may grant provisional accreditation and may require one or more written status reports if, from its review of the survey report, it identifies no significant areas of concern related to performance in accreditation elements, compliance with standards, and planning for the later stages of the medical education program.

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 Provisional Survey Visit Preparation, is intended to help schools navigate the various stages of the provisional 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
  • Designate Survey Personnel
  • Attend LCME Webinars

Timeline

  • 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)

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

Submitting Updates

  • 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

Getting Started

Establish the Survey Visit Date

The LCME Secretariat will contact the dean approximately 12 months prior to the survey visit to establish specific dates. More information about the provisional survey visit can be found in Rules of Procedure and Guide to the Review Process for Provisional Accreditation.

Designate Survey Personnel

Approximately 15 months before the date of the survey visit, the dean designates 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 Guide to the Review Process for Provisional Accreditation.

Attend LCME Webinars

January through October, the LCME Secretariat offers monthly Connecting with the Secretariat webinars that provide general information about accreditation 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.

Provisional Survey Timeline

Months +/- Survey Visit Responsible Individuals/Groups Activities
-18 to -15 LCME Secretariat and Dean
  • Establish and confirm survey visit dates
-15 Dean
-14 FAL
  • Access the DCI for the survey year, available on the LCME publications page.
  • Appoint members to the institutional self-study task force.
  • Assign sections of the DCI for completion by appropriate people/groups
  • Designate team of students to conduct the student survey and write the Independent Student Analysis (ISA)
-13 FAL
  • Distribute completed DCI sections to the self-study task force
-10 ISA Task Force
-10/-5 Self-study Task Force
  • Review and analyze the DCI and the ISA report
  • Prepare the self-study summary report
  • Implement changes to correct issues identified in self-study process
-9 ISA Task Force
  • Distribute survey to student body
  • Note: Because data from the student survey are needed for completion of the DCI, we suggest that the survey should be open for a maximum of one month
  • Since the timing should ensure that students have been in the program for a sufficient amount of time to be able to answer the questions; the survey should be distributed around early spring of the first year.
-8 ISA Task Force
  • Compile student survey data and send to FAL for incorporation into DCI
  • Begin analysis of data
-6 ISA Task Force
  • Provide final ISA report to FAL for distribution to appropriate self-study task force members
-4 FAL and Dean
  • Receive school’s unique Secure Electronic File Transfer (SEFT) account information and survey package submission instructions from LCME Secretariat staff via email; FAL to confirm receipt to lcmesubmissions@aamc.org
-3 FAL and Dean
  • Review survey team member roster from LCME Secretariat staff and send email to dwaechter@aamc.org if a potential conflict of interest is identified
-3 FAL
  • Update DCI, DCI appendices, and self-study summary report with current information
  • Review survey package for consistency and accuracy
  • Submit survey package via school’s SEFT account and email lcmesubmissions@aamc.org to confirm it contains final version of survey package
-2.5 Survey Team
  • Receive team’s unique SEFT account information and instructions, for accessing the submitted survey package, from LCME staff via email
-2.5/-2 Survey Team Secretary (for on-site visits)
  • Upon receipt of the survey package, contact FAL/SVC to:
    • Request supplemental information (if needed)
    • Discuss travel and hotel
    • Coordinate visit logistics, including round-trip daily travel between hotel and school and travel between campus and other sites, as necessary
  • Contact the FAL/SVC to request first draft of visit schedule based on the Visit Schedule Template
  • Email survey team to:
    • Confirm that team members received the survey package
    • Provide travel advice
    • Offer advice on strategy for reading the survey package and drafting the survey report
  • Review draft schedule and list of session participants and contact team chair to discuss preferences
  • Review suggested list of participants at survey visit sessions
  • Email survey team to inform members of:
    • Hotel information
    • Individual writing assignments
-1.5/-1 Survey Team Secretary
  • Email survey team to:
    • Request travel itineraries
    • Secure information about any dietary preferences or requirements
    • Identify any supplemental information team would like from the school
    • Request summary of preliminary impressions from the team
  • Contact faculty fellow and/or other inexperienced team member(s) to provide overview of school visit mechanics and to answer questions
-1 Survey Team Secretary
  • Request supplementary information from the SVC and the FAL, as needed
-1 Dean/FAL
  • Last date for school to send “unsolicited updates” to the survey team (must be submitted 30 calendar days before survey visit begins)
-.5 Survey Team Secretary and Survey Team
  • Email survey team the consolidated summary of preliminary findings; discuss with team, as needed
  • Finalize visit schedule with school
  • Optional: Telephone conference call with survey team
Survey Visit Team Chair/Secretary
  • Develop team findings and prepare the survey exit report
Survey Visit Dean/FAL
  • At conclusion of the survey visit, submit final batch updates to the LCME Secretariat via lcmesubmissions@aamc.org or the school’s SEFT account (depending on the size of the files/zip drive)
Survey Visit Survey Team Members
  • Submit draft survey report writing assignments to the survey team secretary within 7-10 business days following survey visit
+1.5/+2 Survey Team Secretary
+2 Survey Team Secretary
  • Send draft survey report and team findings document to the team and then to the dean for review
  • Notify dean of process for requesting significant revisions
  • Request feedback from dean in 10 business days
  • Incorporate dean’s requested changes, as needed
  • Notify dean of the suggested revisions that were and were not incorporated into the report
  • Submit final survey report and associated communications via the team’s SEFT account provided by LCME staff prior to the visit:
    • Final report narrative and Appendix
    • Survey Team Findings
    • All communications TO the dean regarding changes to the survey report
    • All communications FROM the dean regarding changes to the survey report
  • For help in logging in or uploading files, email lcmesubmissions@aamc.org
+2/+6 LCME
Within 30 days of LCME meeting LCME Secretariat
  • Send school officials the accreditation letter containing accreditation action, term, and requested follow-up
+1.5 months following LCME meeting LCME Secretariat
  • LCME Secretariat provides feedback to team members on the LCME’s action on survey team findings.

Completing the DCI

The DCI is available on the LCME publications page and is a Word document that contains questions related to each accreditation element. Some of the questions ask for narrative explanations and some ask that tables be completed.

It is the responsibility of the faculty accreditation lead (FAL) to 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 Review Process for Provisional Accreditation.

Submitting the Survey Package

Survey Package Contents and Due Date

A complete survey package for a provisional survey visit consists of the following:

  • Completed Data Collection Instrument (DCI)
  • DCI Appendix (the supporting documents for each section of the DCI)
  • Independent Student Analysis (ISA)

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 three 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”, and the final ISA in “3-ISA”.

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 lcmesubmissions@aamc.org 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-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.)
  • 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.

DCI Appendix

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.

Example:

  • 2-DCI Appendix
    • _Table of Contents.doc
    • 1-01 Exec Sum Strategic Plan.doc
    • 1-03 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 lcmesubmissions@aamc.org to notify LCME staff and request a confirmation that the files have been uploaded successfully. For example:

SEFT Submission Confirmation Email 1

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).

Questions?

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

Submitting Updates

Typically, there are two types of required updates after the survey package has been submitted: (1) institutional changes, new data, and/or corrections and (2) supplemental information. Details of what, how, and when to submit updates are described below.

Types of Updates

1) 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 should be bundled into one update batch and emailed to the survey team secretary 30 calendar days prior to the survey visit. Provide an update summary with the updates. See the “Common Data Updates” section below for examples.

2) 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 faculty accreditation lead (FAL) and provide instructions about the type of material(s) that should be submitted. This type of update should not be held for batch updates (described above); it should be emailed to the team secretary as soon as it is requested.

Submitting Updates to the Survey Team

Updates to the survey package should be emailed to the survey team secretary. 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.

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.

Submitting the End-of-Visit Update to the LCME Secretariat

Schools are 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 lcmesubmissions@aamc.org. If the update is too large to be emailed, please use the Secure Electronic File Transfer (SEFT) account from your original survey package submission. Email lcmesubmissions@aamc.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

Data Source DCI Location
MCAT scores and GPAs of the most recent matriculating class School Standard 10
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”

Standard 1
Standard 5
Element 5.1

General Update Guidelines

  1. 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.
  2. 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).
  3. 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.
  4. 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.
  5. 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. Only provide pages that contain updates, not the full DCI. 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.

Hosting the Survey Visit

A well-planned survey team visit ensures optimal use of the survey team’s and school personnel’s time.

Below are some highlights for a successful survey visit. Details on hosting the survey visit can be found in the Guidelines for the Planning and Conduct of Accreditation Survey Visits.

  • Use the Timeline tab as a guide for the steps before, during, and after the survey visit.
  • The faculty accreditation lead (FAL) will work with the survey team secretary to establish the survey visit schedule, using the model visit schedule as a starting point.
  • The school will be responsible, in coordination with the team secretary, for making on-site arrangements for the survey team’s visit.
  • The survey visit typically starts on a Sunday evening at 5:00 pm with a team caucus, followed by a meeting with the dean. These meetings typically occur in the team chair’s suite or a conference room in the team hotel.

Hotel

  • The survey visit coordinator (SVC) should make hotel reservations for each survey team member, obtaining an institutional or educational discount, if available. Alternatively, the SVC may wish to coordinate hotel selection with the team secretary.
  • The school should select a full-service hotel, preferably near the campus and convenient to restaurants and taxi service.
  • The hotel should be of appropriate quality, but not extravagant in cost.
  • The school should reserve a suite with a meeting area for the team chair. In some hotels, suites are not available or are prohibitively expensive. In such instances, a small conference room should also be reserved in the hotel for the nights of the survey visit.
  • The school should guarantee the rooms for late arrival and send a reservation confirmation directly to each survey team member.
  • The hotel should be notified that survey team members will be paying their own bills. (Note that the school may reserve and guarantee the rooms, but each team member must arrange to pay for his or her room upon check in, per LCME policy.)
  • The survey team secretary may request that a computer and printer be available in the chair’s suite so that the team can work to develop its report. These arrangements should be discussed and made in advance.

Transportation

  • Each team member will make his or her own airline travel arrangements.
  • Ground transportation to and from the airport may be provided by the school, or it may be left up to each team member if taxi or a car service is readily available. If left up to team members, information for arranging ground transportation should be provided to the team secretary.
  • Transportation to and from the team hotel and the school is to be arranged and provided by the school, as should transportation to any affiliated hospital sites and distributed campuses.
  • The vehicle should be able to accommodate 5 or 6 survey team members with space for luggage.
  • Details about the coordination of pick-up and drop-off timing and location details should be provided to the team secretary in advance of the visit and included in the survey visit schedule.
  • Transportation to and from the team dinners is the responsibility of the team.

Meals

  • Although evening meals are at the discretion of the team, recommendations about area restaurants for the team dinners are always welcomed by the team secretary.
  • The school should provide meals (i.e., continental breakfast, lunch) and snacks while the survey team is at the school.
  • Check with the survey team secretary about any individual team members’ food allergies or preferences.

At the School

  • The survey team will need a “home room” at the school that is equipped with a computer, a printer compatible with the operating system used by the survey team secretary, and a shredder.
  • The home room should have a conference table large enough to accommodate survey team meetings with school personnel.
  • A second meeting room will be needed for any sessions when the survey team divides into two sub-teams.
  • The SVC should ensure that school participants scheduled to be in each session are familiar with when and where they should appear.
  • The SVC should serve as a timekeeper so that sessions do not run late.
  • Tent cards should be provided for each survey team member and for all school personnel with whom the team will meet. Survey team members should also be provided with name tags.
  • The SVC should provide access to a set of materials in the survey team “home room.” This may include an electronic copy of the DCI, copies of self-study subcommittee reports, updates provided to the survey team before and during the visit, and any other documents requested by the team (e.g., course evaluations or syllabi).
  • It is the team secretary’s responsibility to collect copies of all documents distributed to survey team members during the survey visit for possible inclusion in the survey report. The FAL is asked to facilitate this collection of documents by providing the team secretary and each team member with a USB thumb drive containing all materials submitted prior to and during the survey visit. This includes updates, materials handed out during survey visit meetings, and updated attendance rosters for each meeting. No new information is to be provided to survey team members after the conclusion of the visit. See Submitting Updates tab for more details.
  • On the last day of the survey visit, the survey team will need protected time to discuss survey team findings and assemble those findings into an exit report that will be delivered to the dean and institutional leadership in brief presentations at the conclusion of the visit.
  • The dean will have the opportunity to respond, in writing, to the team findings and report narrative when he or she reviews the draft survey report.

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