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2021-22 Limited Survey

A limited survey visit is generally requested by the LCME following its review of a full survey visit report or a status report, or following an external event that has raised concern about the quality of the medical education program (e.g., a financial crisis, a major natural disaster). A limited survey visit thus focuses on the specific concerns or issues that were identified in a previous survey visit or in a status report or following the external event.

Team Composition & Responsibilities

A limited survey team is created by the LCME Secretariat on an ad hoc basis following direction of the LCME; in some instances, it may consist of only two members of the LCME Secretariat in order to permit a rapid response. When a limited survey team consist solely of members of the LCME Secretariat, it is traditionally referred to as a Secretariat fact-finding visit. When a limited survey team includes a member who is not a member of the LCME Secretariat, it typically consists of a team chair, a team secretary, and one team member. All limited survey team members are expected to participate in LCME team training.

Team Chair

The survey team chair for a limited survey visit is typically a current or recent medical school dean or LCME member or a member of the LCME Secretariat; he or she functions as the official voice of the survey team and leads its deliberations. The team chair works closely with the team secretary to review the school’s accreditation history, including the team report from the most recent survey visit and any status reports. During the survey visit, the chair makes introductions and explains the purpose of the survey. The chair leads the discussions as the team develops its findings about the medical education’s program’s performance in accreditation elements. The team chair reports the team’s findings to institutional executives at the conclusion of the survey visit.

Team Secretary

The survey team secretary for a limited visit is often a member the LCME Secretariat and is responsible for developing the visit schedule, coordinating visit arrangements with the school, and producing the survey report. The team secretary handles oral and written communication with the school, other team members, and the LCME Secretariat. The secretary is responsible for compiling the survey report from the written findings prepared by survey team members. The team secretary works closely with the team chair.

Team Member

Limited survey team members are selected from a pool of experienced medical educators and practitioners and medical school administrators. Team members are selected based on their areas of expertise and their familiarity with a given academic environment. The LCME Secretariat makes all reasonable efforts to balance the survey team in terms of accreditation experience, gender, race, ethnicity, professional expertise, practitioner/educator status, and familiarity with the type of institution being surveyed.

No member of the limited survey team will have participated in the previous full survey visit. A similar effort is made to avoid appointing team members with any substantive prior affiliation with the school in order to avoid real and perceived conflicts of interest. Once the LCME Secretariat has assigned team members, the dean has an opportunity to review the team roster. If the dean has reason to believe that a team member has a potential conflict of interest that should disqualify him or her from evaluating the program, the dean may contact the LCME Secretariat to determine whether an alternate team member can be appointed. Final decisions about survey team membership are made by the LCME Secretariat.

Timeline

A limited survey visit is scheduled by the LCME as a result of an unforeseen situation (e.g., concerns resulting from a survey visit or from information contained in a status report or resulting from an external threat to the integrity of a medical education program). A limited survey visit will generally focus on the specific issues that triggered the need for the survey visit, but it is not necessarily limited to those issues if the team discovers other concerns during the survey visit. The team will receive the school’s briefing book and other relevant survey materials from the LCME Secretariat approximately six weeks prior to the scheduled visit (For a complete list of materials see Preparing for the Survey Visit tab); the briefing book is created by the school upon direction by the LCME to address the issues that are the basis of the visit. The team secretary, who is usually a member of the LCME Secretariat, will use the email templates (See the Templates Tab) when communicating with team members and with the school’s Faculty Accreditation Lead (FAL). The due date for the final report will be provided by the Secretariat.

Visit Schedule

The survey team secretary has ultimate responsibility for developing the visit schedule; he or she works with school officials to organize the visit schedule so as to focus on the issues highlighted in the letter of accreditation to the school following the full survey. The team secretary builds the visit schedule in such a way as to ensure that all accreditation elements in the briefing book can be addressed. Limited survey visits typically begin late on Sunday afternoon and end on Tuesday or Wednesday. The survey visit begins with a team caucus on Sunday afternoon, followed by a meeting with the dean.

During the survey visit, the team meets with those persons or groups who can provide or verify information about the accreditation elements under review, including faculty, students, administrators, and/or representatives of clinical affiliates. While meetings with faculty members and students typically take place without the presence of members of the institution’s leadership, the dean’s participation is appropriate during the team’s meetings with some program administrators, especially regarding finances.

The team successively develops and refines its list of summary findings, beginning at the Sunday team caucus and continuing during working sessions each evening and prior to the exit conferences. Survey visits typically conclude with two exit conferences – the first with the dean and the second with the dean, the university chief executive, and other institutional officials identified by the school. At the exit conferences, the team chair reads the statement that includes a summary of the survey team’s findings. The team chair provides a copy of the team’s findings to the dean. The team chair emphasizes to both the dean and the university chief executive that the survey team’s summary report represents a preliminary statement of findings for consideration by the LCME. The team’s findings are not, therefore, for widespread dissemination at this point.

Templates

The LCME Secretariat provides a number of templates to assist team secretaries in fulfilling their responsibilities to communicate with the school and with team members, organize the survey visit, and complete the survey visit report. Team secretaries are asked to review the templates and modify them according to their preferences, styles, and specific needs, while retaining any required information.

Team Secretary Activity

Template

Begin to discuss the survey visit schedule. Send logistical requirements and visit preferences to the school’s FAL. Sample email to Faculty Accreditation Lead (FAL)
Send team members visit details and, optionally, writing assignments. Sample email to team members
Send initial and/or introductory note to the team chair. Sample email to team chair
Request a revised survey visit schedule and or additional participants based on reading of accreditation materials (this is not always required). Sample email to FAL
Send draft survey visit schedule, writing assignments, hotel information, and report-writing resources to team members. Sample email to team members
Send updated survey visit schedule and draft survey report outline to team members. Sample email to team members

Request initial survey team findings from team members.

Some team secretaries find it helpful to hold a conference call with the team to discuss survey team findings. Secretaries are welcome to use the LCME conference call line and can email lcme@aamc.org to receive call-in information.

Sample email to team members
Request supplemental information from the school (as needed). Sample email to FAL
Send consolidated list of survey team findings to team members. Sample email to team members
Two exit conferences are typically held on the last day of the survey visit to share survey team findings, first with the dean and then with the dean and the chief institution official (e.g., university president). The survey team findings are added to the exit report. At the first exit conference, the exit report is handed to the dean and read aloud, verbatim, by the team chair. The information in this template must be communicated to the dean in its entirety. It is the dean’s decision whether or not to provide the written exit report to the chief institutional official at the second exit. Exit Report Template for Limited Accreditation Surveys
Send first draft survey report and survey team findings to lcmesubmissions@aamc.org. LCME staff will send draft report and finding to the LCME Secretariat for review. Sample email to LCME Secretariat staff
Receive edited draft report and findings via email from LCME Secretariat and carefully review edits and comments. Discuss edits with the team chair and incorporate the agreed-upon edits into the report and findings. Notify the Secretariat via lcmesubmissions@aamc.org regarding the decisions about the Secretariat’s suggestions.
Send revised draft survey report and team findings document to dean. Sample email to dean
Send revised draft survey report and team findings document to team members for review. Sample email to team members
Respond to dean’s comments on the survey report and survey team findings. Sample email to dean

By the due date set by the Secretariat, submit (via the team’s SEFT account) a clean copy of the final survey report, including both the narrative and the appendix, the survey team findings document, and a copy of all communications to/from the dean regarding changes to the survey report.

Email lcmesubmissions@aamc.org to notify LCME Secretariat staff that the final material has been submitted.

Sample email to LCME Secretariat staff

Preparing for the Survey Visit

Resources

Approximately six weeks prior to the survey visit, each survey team member will receive an email from the LCME Secretariat with Secure Electronic File Transfer (SEFT) account information and instructions. It is recommended that you copy and paste the username and password into the SEFT account login, rather than hand typing letters/numbers. The SEFT account is how the survey team will access material relevant to the survey visit and will contain the following material:

  • LCME Publications (also available on Standards, Publications, & Notification Forms)
    • Functions and Structure of a Medical School
    • Rules of Procedure
    • Guidelines for the Planning and Conduct of LCME Accreditation Survey Visits
    • Survey Report and Team Findings Guide for Limited Accreditation Surveys 
    • Survey Report Template for Limited Survey Visit Reports 
    • Survey Team Findings Template for Limited Accreditation Surveys 
    • Exit Report Template for Limited Accreditation Surveys 
  • Survey Team List
  • Confidentiality Statement & Conflict of Interest Statement
  • Agreement by a Medical Education Program (agreement regarding consultative services)
  • Important Travel Logistics
  • AMA Travel Reimbursement Policy
  • Expense Reimbursement Excel Form
  • Notice to Team Secretary
  • School’s Background Information since Last Survey Visit
    • Accreditation Letters(s)
    • Survey Reports(s)
    • History Since Last Survey Visit
  • School’s Briefing Book and Appendix

Please note, this is the same SEFT account the survey team secretary will use to submit the final survey report (the narrative and survey report appendix), survey team findings document, and correspondence with the dean regarding changes to the survey report. Final submission must be at least five weeks before the LCME meeting at which the survey report is scheduled to be reviewed. Once all documents have been added to the SEFT account, the survey team secretary must email lcmesubmissions@aamc.org to notify LCME Secretariat staff that the final material has been submitted. LCME Secretariat staff will reply to confirm successful submission within one business day. (The team secretary should email the draft survey report and survey team findings to lcmesubmissions@aamc.org for Secretariat review, not SEFT).

Before the Visit

All Team Members Will:

  • Be alert to any possible conflict of interest they may have as a team member – if a team member identifies a potential conflict of interest related to participation in the survey visit, he/she should contact the LCME secretariat immediately
  • Read all of the school-submitted materials
  • Review all of the school’s background information since the last full survey, paying particular attention to the accreditation letters for the LCME’s findings and specific instructions for conducting the visit
  • Identify any issues that might result in the school’s performance in one or more elements being found to unsatisfactory or satisfactory with a need for monitoring
  • Identify any issues that require clarification during the survey visit
  • Address any questions they may have to the team secretary
  • Complete a first draft of their writing assignments
  • Book their own travel, arriving in time for the initial team caucus on Sunday afternoon and departing after the exit conferences on Wednesday (or Thursday if additional time is needed to visit regional campuses)

Team Secretary Will:

  • Work with the school to develop the survey visit schedule
  • Work with the school to request any updates to the submitted material
  • Work with the school on logistics
    • Hotel
    • Local travel – between airport and hotel, hotel and school, school and airport
    • IT support for team members’ electronic devices
  • Provide information and instructions to survey team members
    • Logistics – where and when to arrive
    • Team writing assignments
    • Collect team members’ initial lists of issues that might result in the school’s performance in an elements being unsatisfactory or satisfactory with a need for monitoring

During the Visit

All Team Members Will:

  • Actively participate in the Sunday evening team caucus
  • Lead the sessions for which they are responsible and make sure that all of their questions are answered
  • Be prepared to ask any questions they may have in those sessions that they are not leading
  • Actively participate in each night’s team meetings

Team Secretary Will:

  • Coordinate information updates with the school
  • Ensure that team members discuss and come to a consensus about the school’s performance in each element and develop an ongoing set of survey team findings
  • Keep the sessions running on schedule (in collaboration with school personnel)
  • Prepare the exit report
  • Set expectations regarding the date on which team members’ survey report writing assignments are due

Team Chair Will:

  • Lead the Sunday evening team meeting with the dean
  • Start the survey visit sessions, with introductions and information about the purpose of the survey visit and the structure of the sessions
  • Lead the exit conferences at the conclusion of the visit

After the Visit

All Team Members Will:

  • Submit writing assignments by the deadline set by the team secretary
  • Review and comment on the draft survey team report
  • Promptly submit reimbursement forms and receipts to the LCME Secretariat

Team Secretary Will:

  • Edit the report carefully before the LCME Secretariat’s review
  • Follow the steps for the team’s and school’s review of the draft survey report
  • Follow the instructions for submitting the final survey report, survey team findings, and any correspondence with the dean (More information can be found on the Survey Report and Submission Tab)
  • Receive, complete, and submit the evaluation form to lcmesubmissions@aamc.org about the survey visit

Team Chair Will:

  • Work with the team secretary to resolve any concerns about the draft survey report and/or survey team findings document
  • Receive, complete, and submit to lcmesubmissions@aamc.org the evaluation form about the survey visit

Travel and Reimbursement

Hotel

The medical school will make the hotel reservations for team members, in consultation with the team secretary, and then provide team members with relevant information. Upon check-in, each team member should provide credit card information to pay for his or her own hotel bill. Hotel room expenses should NOT be charged to the school.

LCME Reimbursement Form (Excel document)

To receive reimbursement for travel expenses, each team member should complete the Non-Staff Electronic Travel Worksheet (Excel document). Team members should send the completed Excel document [please do not PDF the Excel document] and PDFs of original receipts to the Chicago LCME Secretariat office: ama.lcme@ama-assn.org within 30 days following the survey visit.

Travel Policy and Logistics

Please read the LCME reimbursement policy document prior to booking your travel. The travel policy includes the following:

  • Premium/First Class airline seating is non-reimbursable.
  • Airline insurance is non-reimbursable.
  • Itemized expenses are required and receipts are required for expenses of $25.00 and above.
  • No receipts are required for expenses less than $25.00. However, itemization and/or explanation is required for each expense.

Air Travel – Non-Staff Booking Instructions

All team members are encouraged to make their air travel arrangements as soon as possible. Team members may make their travel arrangements using the BCD Travel reservation instructions so that the Chicago LCME Secretariat office will be billed directly for the air travel. Any team member interested in using this service should contact Marina Ramos at marina.ramos@ama-assn.org to request a username and temporary password. After entering the BCD Travel website, please change the password under the profile tab. Since you are only booking flights, “uncheck” the hotel and car options.

Airport Pick-ups/Drop-offs

Depending on the location of the medical school, the school may arrange for pick-ups and drop-offs. This should be discussed with the team secretary. The team secretary will forward information from the school to the team members. The potential use of a rental car requires prior authorization from the team secretary.

Questions?

Contact Marina Ramos at 312-464-4662 or marina.ramos@ama-assn.org.

Survey Report Submission & Review

(for more detail, see the Survey Report and Team Findings Guide for Limited Accreditation Surveys)

Completing the Draft Survey Report and Survey Team Findings Document

  • Survey team members complete their specific writing assignments within the Survey Report Template for Limited Survey Visit Reports as a guide.
  • The survey report addresses each accreditation element that the team reviewed and includes the survey team’s detailed findings and its recommendations on the school’s performance for each element (i.e., satisfactory, satisfactory with a need for monitoring, or unsatisfactory).
  • The reasons and evidence that elements are identified as satisfactory with a need for monitoring or unsatisfactory must be clearly explained in the survey report narrative.
  • All tables in the survey report must reflect the most current information that was available at the time of the survey visit.
  • The team secretary completes the appendix.

Assembling the Draft Survey Report

  • Team members email their completed writing assignments to the team secretary.
  • The team secretary assembles all team members’ writing contributions into a single report using the Survey Report Template for Limited Survey Visit Reports
  • The team secretary reviews the complete draft survey report to ensure that there is sufficient detail and that all sections have been completed/updated.
  • The team secretary edits the draft survey report for clarity, consistency, formatting, and typographical errors.
  • The survey team findings document is prepared by the team secretary from the exit report using the Survey Team Findings for Limited Survey Visit Reports template. The survey team findings are organized by standard and category of recommendation (i.e., satisfactory with a need for monitoring, unsatisfactory), with the headings for standards and categories deleted if there are no survey team findings related to them.

Submitting the Draft Survey Report and Survey Team Findings for LCME Secretariat Review

  • Before submitting the draft survey report to the LCME Secretariat, the survey team secretary should carefully proofread the survey report to correct spelling, typographical, grammatical, and punctuation errors and to ensure that all questions are answered and all tables are complete and include the most current data.
  • The team secretary sends the draft survey report and survey team findings document to lcmesubmissions@aamc.org.
  • The draft survey report and survey team findings document are reviewed by two members of the LCME Secretariat, who ensure the report is complete, sufficient information has been included related to each element, that the findings are clear and well-documented in the survey report, and that the findings reflect current LCME expectations about performance for elements. They also determine whether the language in the survey report indicates any possible additional survey team findings.
  • Edited survey report with track changes and comments from the two LCME Secretariat reviewers is returned via email to the team secretary.

Team Members’ Review of the Draft Survey Report

  • The team secretary discusses the edits from the Secretariats with the team chair and incorporates the agreed-upon edits into the report narrative and survey team findings.
  • The team secretary notifies the Secretariat via lcmesubmissions@aamc.org regarding the decisions about Secretariat’s suggestions.
  • The team secretary sends revised survey report and team findings document to the other members of the survey team.
  • The team secretary emails revised survey report and team findings document to all survey team members with summary of changes made based on Secretariat review and the reasons for changes.
  • The team members have 5 business days to review the survey report for editorial changes; to ensure it is clear, complete, and reflects the survey team’s consensus; and to email revision to team secretary.
  • The team secretary reviews suggestions from team members and consults with the team chair if one or more substantive changes have been recommended in the content of the survey report or the survey team findings document.
  • The team secretary notifies the LCME Secretariat via lcmesubmissions@aamc.org regarding the team’s decisions about final team findings.
  • After incorporating any further edits from team members or the LCME Secretariat, the team secretary sends the survey report and survey team findings document to the dean.

The Dean’s Review of the Draft Survey Report and Survey Team Findings

  • Team secretary emails the dean a clean copy of the revised survey report and survey team findings document with instructions for the dean to respond via email within 10 business days to:
    • Identify errors of fact and provide corrections only if supporting information was the survey package or provided to the team prior to or during the survey visit

Preparation of the Final Survey Report and Survey Team Findings Documents

  • Team secretary considers edits and comments from the dean with evidence provided to support changes.
  • Team secretary discusses any of the dean’s requested changes that might lead to amendments to the survey team findings document with the team chair.
  • Team secretary revises the survey report and/or team findings document based on the comments from the dean and input from the team chair.
  • Team secretary emails dean with a summary of what changes requested by the dean were made and what changes were not made in the survey report and/or survey team findings document. In that communication, the dean should be reminded that remaining issues related to the process of the visit can be put in a letter addressed to the LCME Secretariat and sent to lcmesubmissions@aamc.org for consideration by the LCME. The letter may not address the survey team’s findings or the substance of the survey report narrative.

Submission of the Final Survey Report and Survey Team Findings Documents to the LCME

  • Team secretary uploads clean copies of the following material to the team SEFT account, by the due date provided by the Secretariat:
    • Final survey report narrative
    • Final survey report appendix
    • Final survey team findings document
    • Copy of all communications to/from the dean regarding changes to the survey report and/or survey team findings document
  • Team secretary emails lcmesubmissions@aamc.org to notify LCME Secretariat staff that the final material has been submitted.
  • The LCME Secretariat staff email the team secretary to confirm successful submission within one business day.

Follow-up to Survey Team Members Regarding Any Changes Made to the Survey Team Findings by the LCME

  • After the LCME has acted on the survey report and survey team findings document, the members of the survey team will receive a letter from the LCME Secretariat on the changes, if any, to the team’s findings that were made. This step is meant to assist the survey team in understanding the LCME’s expectations related to performance on elements.