SOM Accreditation
The Self-Study Process for LCME Accreditation
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General Steps in the Accreditation Process
Components of the Self-Study Summary Report
Independent Student Analysis (ISA)
Accreditation
- Aims are: (1) to promote institutional self-evaluation and improvement and (2) to determine whether a medical educational program meets prescribed standards
- Accrediting body is the Liaison Committee on Medical Education (LCME)
- Evaluation is completed using 12 overarching standards with 92 elements (90 elements for schools without regional campuses)
General Steps in the Accreditation Process
- Completion of the data collection instrument (DCI) [part of the self-study], the independent student analysis (ISA), and compilation of supporting documents
- Self-Study Analysis
- Summary Self-study Report Development [part of the self-study]
- Survey Visit
- Action on Accreditation Findings
Overview of the Self-Study
- Brings together representatives of the administration, faculty, student body, and others who constitute an institutional self-study task force
- Seeks broad participation from among stakeholder groups to participate on self-study subcommittees
- Guided by the faculty accreditation lead (FAL), Dr. Loretta Jackson-Williams, Vice Dean for Medical Education
- Completes three primary responsibilities
- Collect and review data about the medical school and its educational program
- Identify both institutional strengths and challenges that require attention
- Define strategies to ensure the strengths are maintained and problems are addressed effectively
- Produces a summary report that includes an evaluation of the quality of the medical education program and the adequacy of resources to support it, due 14 weeks prior to the survey site visit
Self-Study Subcommittees
The self-study task force comprises administrators, faculty, and students and determines the objectives of the self-study, sets a timetable for the completion of activities, and finalizes the summary self-study report. There are several subcommittees each focusing on specified standards.
- Institutional Setting Subcommittee (Standards 1, 2, and 5)
- Educational Program Subcommittee (Standards 6, 7, 8, and 5.2)
- Medical Students Subcommittee (Standards 10, 11, and 12)
- Faculty Subcommittee (Standard 4)
- Academic and Learning Environment Subcommittee (Standards 3 and 9)
Subcommittees produce subcommittee reports and submit them to the task force chair. Reports should include thoughtful, evidence-based analysis of each area and lead to: (1) conclusions about programmatic strengths and challenges and (2) recommendations for actions to resolve any identified problems.
Components of the Self-Study Summary Report
- Introduction describing the self-study process with membership categories of self-study task force members and brief history of recent major changes relevant to performance in accreditation elements
- Summary organized into sections of institutional strengths, challenges/areas of concern relevant to performance in accreditation elements including actions undertaken or planned to address each challenge/area of concern
Independent Student Analysis (ISA)
- Survey of student satisfaction of topic areas relevant to students by students in all classes
- ISA completion while DCI is being completed by the institutional self-study task force
This document is a summary of the LCME Guide to the Institutional Self-Study. 2026-27_Self-Study-Guide_Full_2025-05-22.docx. Accessed June 23, 2025.