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RULES OF PROCEDURE
Liaison Committee on Medical Education
(Revised October 2007)

Table of Contents
(Use links in Table of Contents to access particular topics.)

INTRODUCTION

The Liaison Committee on Medical Education (LCME) was founded in 1942 to unify the separate accreditation activities of the Association of American Medical Colleges (AAMC) and the Council on Medical Education and Hospitals of the American Medical Association (AMA). Since the advent of the Higher Education Act adopted by the United States government in 1965, the LCME has been recognized by the U.S. Department of Education as the reliable authority for the accreditation of programs of medical education leading to the M.D. degree.

Scope of LCME Responsibility

The LCME accredits complete and independent medical education programs whose students are geographically located in the United States or Canada for their education, and which are offered by universities or medical schools that are chartered in the United States or Canada.

Overview of Accreditation

As practiced in the United States today, accreditation is a process by which institutions 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, graduates, the medical profession, healthcare institutions, and the public that (1) educational programs culminating in the award of the M.D. degree meet reasonable and appropriate national standards for educational quality, and (2) graduates of such programs have a complete and valid educational experience sufficient to prepare them for the next stage of their training. LCME standards for educational program quality are contained in the document Functions and Structure of a Medical School, available electronically from the LCME web site (www.lcme.org), or in print by request to the Secretariat offices.

The LCME makes periodic evaluations of medical education programs in the United States and its territories. It also evaluates M.D.-granting programs in Canada in cooperation with the Committee on Accreditation of Canadian Medical Schools (CACMS). A list of medical schools offering accredited programs leading to the M.D. degree is published annually in the Journal of the American Medical Association and is available on the LCME web site.

Programs judged by the LCME to meet national standards of quality are designated as "Accredited" for a usual term of eight years. Existing accredited programs that are found to be not in substantial compliance with LCME standards are designated as "Accredited, on Probation." Programs whose accreditation has been withdrawn, those applying for accreditation and not meeting the standards, and those which have not applied for accreditation, are considered "Not Accredited." Approved new programs under development are designated as holding "Preliminary Accreditation" or "Provisional Accreditation" until they demonstrate full compliance with all accreditation standards, at which time their status changes to "Accredited."

Accreditation of Medical Education Programs Outside of the United States

Since its inception in 1942, the LCME has collaborated with the Association of Faculties of Medicine of Canada (AFMC, formerly known as the Association of Canadian Medical Colleges or ACMC) in the accreditation of undergraduate medical education programs in Canada. Beginning in 1979, the collaborating agency for the accreditation of Canadian medical schools has been the Committee on Accreditation of Canadian Medical Schools (CACMS), sponsored by the Council on Medical Education of the Canadian Medical Association and the AFMC.

Canadian and American physicians and health care systems have historically derived mutual benefit from robust exchanges around professional, educational, and clinical advances. These joint ventures extend back beyond the 1910 Flexner Report and include the influential 1984 Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine (the "GPEP Report"). Such collaborative efforts between the two countries have been fostered in part through the formation of new professionals in medical schools shaped by shared standards of performance (i.e., the accreditation process). This situation has been maintained through joint accreditation survey visits, but independent accreditation decisions, by the U.S. and Canadian accrediting bodies, and facilitated by mutual participation in CACMS and the LCME by the chairs and secretaries of the organizations.

The procedures followed in the accreditation of Canadian programs of medical education leading to the M.D. degree are the same as those within the U.S. and its territories, including completion of a Medical Education Database and Institutional Self-study. Survey team members are selected by the CACMS Secretary and principal LCME Secretary. Each team assigned to survey a Canadian medical education program includes a participant from the U.S., and surveys of U.S. programs frequently include a Canadian representative on the site visit team. Changes in accreditation standards require approval from the CACMS and its sponsors as well as from the LCME and its parent bodies.

The LCME does not accredit educational programs leading to the M.D. degree in institutions that are chartered outside the United States and Canada, nor programs provided in foreign countries by U.S. or Canadian medical schools. The LCME does provide information and consultation about medical education standards and the process of accreditation to M.D.-granting programs that are located outside of the United States and Canada, at their request.

I. LCME ORGANIZATION

A. Roles and Responsibilities of the LCME's Sponsoring Organizations: the Association of American Medical Colleges and the Council on Medical Education of the American Medical Association

The LCME conducts its evaluations of medical education programs and makes decisions about the accreditation status of such programs autonomously, with no discussion, review, or participation by its sponsoring organizations. The LCME retains final authority for the adoption of new and revised accreditation standards and policies.

The organizations that sponsor the LCME provide financial and administrative support for its operation, appoint the LCME's professional and student members, and participate in the process for reviewing and approving accreditation standards. Financial and administrative support includes the following:

For activities related to Canadian medical education programs, the LCME and CACMS apportion financial responsibility to their respective sponsoring organizations proportionate to the degree of involvement of the two accrediting agencies. For example, expenses of Canadian site visitors for the evaluation of Canadian programs are borne by the CACMS and its sponsors, while expenses of U.S. participants on Canadian surveys are borne by the LCME and its sponsors.

The sponsoring organizations of the LCME each appoint six professional members and one student member, in consultation with the Secretariat staff within each sponsoring organization.

Each sponsoring organization participates in the review and approval of new accreditation standards and substantive revisions of existing standards; new and revised standards are also reviewed and approved by the CACMS and its sponsoring organizations. Sponsor endorsement of accreditation standards is required before their adoption by the LCME. The LCME makes final decisions regarding the adoption of standards which have been endorsed by the sponsoring organizations.

B. Composition of the LCME

Appointment of Voting Members

The LCME consists of 17 voting members, who belong to one of the following three categories:

1. Professional members representing the medical education and clinical practice communities: The AAMC and AMA each appoint six members in this category, and the chair of the CACMS occupies the remaining professional member position. U.S. professional members are appointed for three-year terms renewable once, allowing a maximum term of six years.

2. Student members: The AAMC and AMA each appoint a student member to the LCME. Student members are appointed for a one-year, nonrenewable term.

3. Public members: The LCME itself appoints two members to represent the interests and perspective of the general public. Public members, like professional members, are appointed for three-year terms renewable once, allowing a maximum term of six years. The LCME's Executive Committee oversees the solicitation of applications and nominations, reviews and interviews candidates (or delegates the interview to the Secretariat), and recommends qualified candidates for approval by the LCME.

Criteria for Membership

1. U.S. Professional Members:

2. Canadian Professional Member: The Canadian member of the LCME is the chair of the CACMS.

3. Student Members

4. Public Members

Co-Chairs

The LCME is led by two Co-Chairs, each one chosen from the professional membership appointed by the AMA Board of Trustees and the AAMC respectively. The Co-Chairs generally serve for a term of two years. The Co Chairs alternate presiding at meetings of the Executive Committee and at meetings of the LCME as a whole. At each regular meeting, one Chair presides over the LCME meeting, while the other presides over the Executive Committee meeting and presents its deliberations and recommendations to the full LCME. The Co-Chair corresponding to the year's principal Secretariat (see below) serves as the LCME voting representative at meetings of the Committee on Accreditation of Canadian Medical Schools, with the other Co-Chair designated as the alternate representative.

Training of LCME Members

New members of the LCME are supplied with all relevant documents and information and are counseled by the Secretariat staff on the accreditation process prior to assuming their duties. Formal orientation sessions for new members typically are held prior to the first meeting they will attend; if circumstances permit, they are also invited to observe an LCME meeting prior to assuming their roles. In addition, all members are expected to attend, whenever circumstances permit, orientation sessions and workshops conducted by the LCME Secretariat staff.

C. LCME Staff

The formal responsibilities for managing the LCME alternate annually between two Secretaries, one appointed by the AAMC and one by the AMA. The AAMC-designated Secretary takes primary management responsibility for academic years beginning on July 1 of even-numbered years; the AMA-designated Secretary directs the Secretariat for academic years beginning on July 1 of odd-numbered years. The Secretary with primary management responsibility in any given academic year is designated as the "principal Secretary" and serves as the official administrative voice for LCME activities during that year. Notwithstanding the "principal Secretary" designation, both Secretariat offices continuously engage in the conduct of LCME business and collaboratively support LCME activities.

The Secretaries are employed by the sponsoring associations, and may have responsibilities within their respective sponsor organizations in addition to their roles as LCME Secretaries. Each Secretary is supported by an Assistant Secretary and administrative staff. Independent legal counsel attends all LCME meetings and advises the membership and Secretariat as needed on legal issues relating to accreditation activities.

Functions of the Secretariat

The two LCME Secretariat Offices support the operation of the LCME and manage the accreditation system. Major responsibilities of the Secretariat as a whole include the following:

D. Standing and Ad Hoc Committees of the LCME

Executive Committee

This standing body, with no independent powers, facilitates the work of the LCME by considering issues and presenting recommendations for action to the full LCME. The Executive Committee develops or authorizes proposals for changes in LCME policies and procedures; reviews proposed changes in accreditation standards; coordinates the review and revision of LCME documents; appoints the members of ad hoc subcommittees or working groups to deal with specific issues; initially reviews complaints about the LCME; and, as appropriate, advises the Secretariat on the business and affairs of the LCME between regularly-scheduled meetings. When a vacancy exists for one of the LCME's public members, the Executive Committee initiates the search and evaluates candidates for appointment. Recommendations arising from the deliberations of the Executive Committee are presented to the LCME for official action.

The Executive Committee consists of the LCME Co-Chairs, one AAMC-designated professional member, one AMA designated professional member, and the CACMS professional member. Acting as staff to the Executive Committee are the LCME Co Secretaries and Assistant Secretaries, the CACMS Secretary, and LCME legal counsel. The LCME Co-Chairs alternately preside at Executive Committee meetings.

Subcommittee on Standards

This standing subcommittee of the Executive Committee is responsible for ongoing review of individual accreditation standards, periodic review and revision of Functions and Structure of a Medical School as a whole, consideration of ideas for new standards, and drafting of new standards and annotations. Recommendations from the Subcommittee are presented to the Executive Committee and then, through the Executive Committee, to the LCME for action.

The Subcommittee on Standards is appointed by the Executive Committee and consists of two professional members from each sponsoring organization and one "at large" member from any of the voting membership categories. Other members of the LCME may be invited to serve as consultants to the Subcommittee related to work on specific standards.

Subcommittee on Policy

This standing subcommittee of the Executive Committee is responsible for review and analysis of organizational policy or procedure issues referred to it by the Executive Committee or by the LCME as a whole, periodic review of the policy document Rules of Procedure, and monitoring of changes in the environment of academic medicine that may affect LCME policies or procedures. Recommendations of the Subcommittee on Policy are presented to the Executive Committee for further action.

The Subcommittee on Policy is appointed by the Executive Committee. It consists of two professional members from each sponsoring organization, and one representative (member or staff) from the CACMS. At least one member of the subcommittee should be a member of the Executive Committee, who serves as a liaison between the two groups. Other members of the LCME may be invited to serve as consultants to the Subcommittee related to work on specific policy issues.

Ad Hoc Committees

The LCME may designate ad hoc committees or working groups at its discretion to address policy issues, accreditation standards, or other matters deemed important for the effective functioning of the organization. Where appropriate, such committees may include participants who are not members or staff of the LCME. The Executive Committee of the LCME is generally responsible for appointing the members of ad hoc committees except those ad hoc subcommittees for reviewing complaints and appeals (which are appointed by the Secretariat and the co-chairs).

II. Policies on the Accreditation of M.D.-Granting Programs

A. Term of Accreditation

Programs are normally subject to review on an eight-year cycle. However, the LCME may vote to advance the date of a full survey visit, so that the school has a full review in less than eight years, if there are questions about the sustainability of educational program quality.

New programs seeking LCME accreditation undergo a stepwise review process (described below) until their charter class graduates and full accreditation is awarded. When a new program receives full accreditation, that status is in effect for the balance of the eight-year period that began when the school first received preliminary accreditation status.

An educational program leading to the M.D. degree, once accredited, remains accredited until the program voluntarily terminates its accreditation status or the LCME terminates the program's accreditation through a formal action. Accreditation status does not change until a formal action is taken by the LCME. When the LCME withdraws accreditation, the letter transmitting that decision specifies the date at which accreditation ceases.

B. Entities Eligible for LCME Accreditation

The LCME accredits only complete and independent medical education programs where students are geographically located in the United States or Canada for their education, and that are operated by universities or medical schools that are chartered in the United States or Canada. Accreditation is awarded to the medical school, college, Faculty, or other entity that provides such programs. Branch or alternate campuses of institutions that provide M.D.-granting programs are not eligible for LCME accreditation separate from the accreditation awarded to the parent institution unless they meet the conditions described in the next paragraph. The LCME does not separately accredit segments of educational programs (for example, two-year basic science programs) nor distinct alternative instructional approaches ("tracks") within an educational program.

If a medical school in the U.S. or Canada provides more than one complete and independent medical education program leading to the M.D. degree, and (a) each such program and its students are located within the geographic scope of the U.S. and Canada, and (b) the diplomas awarded for each such program are clearly differentiated, the LCME will separately accredit the programs. If a U.S. or Canadian institution that provides an LCME-accredited M.D.-granting program also offers other medical education programs leading to the M.D. degree that are not accredited by the LCME, regardless of the location of the unaccredited program(s), the diploma for the unaccredited program(s) must clearly distinguish the unaccredited degree program to assure that it will not be confused with the program accredited by the LCME.

The LCME interpretation of a complete M.D.-granting program assumes that all required instructional units (courses and clerkships) are provided by the institution which offers the accredited program, thus ensuring compliance with relevant accreditation standards. The LCME recognizes that accredited programs may wish to broaden learning opportunities for their students, which could include education in programs not accredited by the LCME or CACMS. While educational experiences in programs not accredited by the LCME or CACMS may be of high quality, and hence of substantial value to students, there is no guarantee that such experiences would conform to all accreditation requirements. To assure ongoing compliance with accreditation standards, programs should restrict learning opportunities in non-accredited programs to elective courses, and not required courses or clerkships. [Paragraph added and approved by the LCME, February 2006.]

C. Fees for Accreditation Reviews

There are no fees associated with the accreditation survey process for M.D.-granting programs that are already accredited by the LCME and/or CACMS. New programs seeking preliminary accreditation, and unaccredited programs seeking full accreditation, must pay an administrative fee of $25,000. All expenses related to Secretariat consultations and survey visits will be charged to the program until it receives full accreditation status. Programs that are denied any accreditation status may reapply as described below, and pay a reapplication fee of $10,000. Programs reapplying for accreditation are responsible for all expenses related to Secretariat consultations and survey visits until full accreditation is awarded.

Expenses for consulting visits to programs contemplating application for accreditation are to be reimbursed by those programs.

D. The Accreditation Survey Process

The Survey Process for Complete Medical Education Programs

The evaluation process for complete and independent but unaccredited medical education programs, and for existing accredited programs, consists of comprehensive institutional self-study, on-site evaluation by a team of peer reviewers, and LCME review of the report of the survey team and any other relevant documentation.

For programs that are already accredited, the LCME Secretariat will contact the institution approximately 21-24 months before the anticipated date of their next accreditation survey to establish specific dates for the on-site review. For unaccredited complete medical education programs, the Secretariat will establish the dates for on-site review upon receipt of a written request for evaluation and the accompanying fee of $25,000.

After visit dates have been determined, the Secretariat will send to the dean of the program all materials needed to conduct an institutional self-study and complete a corresponding Medical Education Database. Instructions for conducting the self-study are included in the LCME document Guide to the Institutional Self-Study, available on the LCME web site. Both the self-study guidebook and Medical Education Database (also available on the LCME web site) are subject to annual review and revision. Programs undergoing the self-study process should be careful to use the documents for the academic year in which their on-site evaluation is scheduled. Secretariat staff are available to answer any questions about the conduct of the self-study or completion of the database.

To assist schools in preparing for upcoming accreditation surveys, the Secretariat staff provide annual orientation sessions in conjunction with the annual meetings of the AAMC and AMA. Secretariat staff are also available for pre-survey consultations either on-site or at one of the Secretariat offices. Schools requesting on-site consultation from the Secretariat staff are responsible for all travel expenses associated with the consultation.

Approximately three months before the dates of the on-site review, the Secretariat provides information to both the program being reviewed and survey team members regarding the program's recent accreditation history, composition of the survey team, and background materials regarding conduct of the site visit and writing of the survey report. If the dean of a program being reviewed has reason to believe that any survey team member has a conflict of interest that should disqualify the person from evaluating the program, he or she should contact the Secretariat immediately to determine if an alternate member can be appointed. Final decisions about survey team membership will be made by the Secretariat. Once the composition of the survey team is established, the program should send the team members and each Secretariat office copies of its self-study summary report, Medical Education Database, and any other relevant materials.

The on-site visit for a full accreditation survey typically begins on Sunday evening with an entrance conference with the dean, and concludes early Wednesday afternoon at oral exit conferences with the dean and with the chief executive or academic officer of the university. The Secretariat will send the dean a form for evaluating the on-site review and the accreditation process in general. Results of such evaluations are used internally by the Secretariat staff to review the performance of team members and the effectiveness of the accreditation process. Program-specific evaluation data provided by the dean will not be shared with the LCME. Team members (including Secretariat staff on survey teams) will not receive evaluation data submitted by the program until after the completion of the final survey report and the LCME decision on the program's accreditation status.

After concluding the on-site evaluation, survey team members compile a written report of their findings. The survey team makes neither recommendations nor decisions regarding the program's accreditation status. A draft version of the report is sent to both Secretariat offices for a preliminary review to verify that the report is complete and adequately documents the team's findings. It is then circulated to team members and to the dean for review. If the dean disagrees about the tone or conclusions of the draft report and cannot resolve those concerns with the survey team, he or she may provide any relevant evidence or arguments in writing to the LCME Secretariat, and the letter will be included in the LCME review of the report.

The LCME reviews the final report of the survey team and any other relevant documentation and determines the accreditation status of the program. Depending on the extent of the program's compliance with accreditation standards, the LCME will take one of the following actions for programs already accredited:

For unaccredited programs, the LCME will take one of the following actions:

When awarding full accreditation to a previously unaccredited program, the LCME will also make a determination regarding the date upon which the accreditation status takes effect. The effective date can not precede the date of the LCME action in awarding full accreditation status.

Details regarding these actions are described in the section on "Accreditation Actions" later in this document. The LCME Secretariat communicates the outcome of the LCME's deliberations, including the program's accreditation status and any follow-up actions, in writing to the university's chief executive officer, with a copy to the dean. A copy of the final survey report is included with the letter communicating the LCME decision.

The Survey Process for New or Developing Programs

New medical education programs leading to the M.D. degree undergo a three-stage, transitional accreditation process prior to achieving full accreditation status. This process is available only for new programs that have not admitted or enrolled any students. Developing programs that have already enrolled students without holding preliminary or provisional accreditation are not eligible for LCME consideration until the educational program is complete (i.e., at least one class of students has graduated). At that time they may apply for full accreditation, with the understanding that if and when full accreditation is granted it will take effect with the next entering class after the decision to grant full accreditation was made. Branch campuses of existing medical schools which intend to begin offering a complete and independent medical education program must initiate the process for new programs prior to admitting any students to the new program.

a. Initiation of review

New programs seeking LCME accreditation should contact the Secretariat for advice and consultation. The process begins formally when the chief executive officer of the institution planning to offer the new program submits a written request to the Secretariat seeking LCME accreditation. The institution must also pay the appropriate application fee: $25,000 if it has never previously applied for accreditation or has not been evaluated for LCME accreditation in the preceding three years, or a reapplication fee of $10,000 if it has been evaluated for accreditation within the previous three years. Secretariat staff are available for additional consultation as needed. Institutions are encouraged to take advantage of such opportunities, in order to facilitate orderly development of the program and full understanding of the accreditation process and standards of evaluation.

b. Stage 1: Consideration for preliminary accreditation

Upon written request for evaluation and payment of the application fee, new programs will receive instructions from the Secretariat regarding the conduct of a planning self-study and completion of a modified Medical Education Database. The modified database provides written documentation of those elements deemed by the LCME to be essential prerequisites to the admission of a charter class. Those prerequisites are summarized in the LCME document "Guidelines for New and Developing Medical Schools." The planning self-study is a self-evaluation of the institution's mission and goals, including an analysis and description of how and when the educational program is expected to achieve full compliance with all accreditation standards.

Prior to receiving preliminary accreditation status, programs must not recruit or advertise for students; solicit or collect application fees; collect application information; initiate a process for reviewing admissions applications; schedule interviews for potential matriculants; or issues letters of admission. Programs engaging in any of the above actions will forfeit their eligibility for consideration as a new program, and may not apply for LCME accreditation until the educational program is complete and at least one class has graduated.

Upon completion of the modified database and accompanying summary report of the planning self-study, the institution submits those documents to the LCME Secretariat staff for screening. The Secretariat will review the materials and determine whether the documentation is adequate or whether additional information is needed from the program. When the documentation is determined to be complete, the Secretariat will request that the LCME authorize a limited survey of the program. If the visit is authorized, the survey team will include at least one member of the LCME and/or one member of the Secretariat staff. The limited survey will be conducted in the same format as limited surveys of fully accredited schools (see details in the section on "LCME Accreditation Actions"), concluding with oral exit conferences with the dean and with university leadership. The survey team will prepare a report of its findings for consideration at the next regularly scheduled meeting of the LCME. [Modification approved by the LCME, February 2007.]

If the LCME determines that the school fully meets the expectations outlined in its Guidelines for New and Developing Medical Schools and has developed satisfactory plans for its educational program, it will grant the status of preliminary accreditation. Once preliminary accreditation is awarded, the program may begin accepting applications for enrollment. If the program does not enroll a charter class within two years of receiving preliminary accreditation, it must reapply for accreditation as a new program and pay a reapplication fee of $10,000.

If the LCME denies preliminary accreditation status to the program, the decision may be appealed according to the appeal procedure described elsewhere in this document. A program which has been denied preliminary accreditation may not reapply for a period of one year from the time the final decision to deny was communicated in writing to the institution. If students are admitted after preliminary accreditation has been denied, the program will forfeit its eligibility for reapplication as a new program and may not apply for LCME accreditation until its educational program is complete (i.e., until at least one class has graduated from the program).

c. Stage 2: Evaluation for provisional accreditation

After receiving preliminary accreditation and admitting a charter class, the program updates its planning self-study and completes additional sections of the Medical Education Database. The Secretariat will schedule a limited visit to take place before the midpoint of the second year of the curriculum, to review progress in the implementation of the educational program and the status of planning for later stages of the program. The survey team will include at least one member of the LCME or Secretariat staff.

If, upon review of the limited survey report, the LCME determines that the program is in full compliance with all relevant accreditation standards, it will grant provisional accreditation status to the program. If minor noncompliance issues are noted, the program still may be granted provisional accreditation, but the LCME may request a written progress report addressing the noncompliance issue(s).

If the LCME determines that there are substantial noncompliance issues that could be resolved within a relatively limited period of time, it may continue the program's preliminary accreditation status for an additional year. If continuation of preliminary accreditation status is granted, the program may be required to cease admitting new students and focus its resources on students already enrolled. The LCME may request a written progress report or conduct a limited or Secretariat survey within the one-year continuation period to assess progress in achieving substantial compliance. If the program demonstrates satisfactory compliance, it may then be granted provisional accreditation status, and may again enroll new students.

If the LCME determines that there are substantial noncompliance issues that can not be resolved within a relatively limited period of time, or that a program whose preliminary accreditation has been continued has failed to remedy the problems identified at the time initial accreditation was continued, it will give notice that it intends to withdraw preliminary accreditation. A decision to withdraw preliminary accreditation is subject to appeal. If the LCME makes a final decision to withdraw preliminary accreditation, it will make every effort to help enrolled students transfer to other accredited programs. If preliminary accreditation is withdrawn, the program may not reapply for LCME accreditation for a period of one year from the time the final decision to withdraw was communicated in writing to the institution.

d. Stage 3: Evaluation for full accreditation

After receiving provisional accreditation status, the program once again updates its self-study and completes the remaining sections of the Medical Education Database. The LCME Secretariat will schedule a full accreditation survey to take place late in the third year or early in the fourth year of the curriculum. If, upon review of the survey report, the LCME determines that the program fully complies with all accreditation standards, full accreditation status will be granted for the balance of an eight-year term that began when the program was granted initial accreditation status. If minor noncompliance issues are found, the LCME may grant full accreditation status but require additional progress reports as necessary.

If the LCME determines that there are substantial noncompliance issues that could be resolved within a relatively limited period of time, it may continue the program's provisional accreditation status for an additional year. If continuation of provisional accreditation status is granted, the program may be required to cease admitting new students and focus its resources on students already enrolled. The LCME may request a written progress report or conduct a limited or Secretariat survey within the one-year continuation period to assess progress in achieving substantial compliance. If the program demonstrates satisfactory compliance, it may then be granted full accreditation status, and it may again enroll new students if it had been required to suspend new admissions.

If the LCME determines that there are substantial noncompliance issues that can not be resolved within a relatively limited period of time, or that a program whose provisional accreditation has been continued has failed to remedy the problems identified at the time provisional accreditation was continued, it will give notice that it intends to withdraw provisional accreditation. A decision to withdraw provisional accreditation is subject to appeal. If the LCME makes a final decision to withdraw provisional accreditation, it will make every effort to help enrolled students transfer to other accredited programs. If provisional accreditation is withdrawn, the program may not reapply for LCME accreditation for a period of one year from the time the final decision to withdraw was communicated in writing to the institution.

E. Survey Teams

Selection and Training of Surveyors

The LCME Secretaries are responsible for recruitment and training of a suitable group of surveyors who are knowledgeable about medical education and practice. Schools with upcoming full accreditation surveys are asked to designate a senior administrator or faculty member with leadership responsibilities, with no prior site visit experience, who can participate in a full survey as a "faculty fellow" before the nominating school begins its own self-study process. Apart from faculty fellows, deans of schools to be surveyed within the following year or two, and newly appointed deans, are given particular consideration for survey team assignment. The Secretaries may also solicit nominations for new survey team members when there is a perceived need for specific kinds of surveyor expertise (for example, student or faculty affairs).

The Secretariat staff holds an annual training workshop for new and experienced surveyors in conjunction with the annual meeting of the AAMC. Additional workshops may also be offered for certain categories of team members (such as team secretaries). All new surveyors are expected to take part in the surveyor workshop before participating in a site visit; experienced surveyors should attend such workshops at least once every two years.

Survey Team Size and Composition

a. For full accreditation surveys

For schools undergoing a full accreditation survey (requiring self-study and completion of the Medical Education Database), the survey team will normally consist of five members. The team will include at least one representative of the LCME (either voting member or staff), at least one physician actively engaged in medical practice, and one or more medical educators who possess a doctoral-level graduate or professional degree and have held a faculty appointment at an LCME-accredited medical school for a period of at least five years. [Modifications approved by the LCME, June 2007.] One of the team members is designated as the chair of the team. The team chair, typically a current or recent former medical school dean, functions as the official voice of the team and leads its on-site deliberations. Another member is designated as team secretary, responsible for visit preparations and logistics and the compilation of the survey report. The remaining three team members will generally include a "faculty fellow" (as noted previously) who functions as a regular team member. In appointing full survey teams, the LCME Secretary responsible will make all reasonable efforts to balance the team in terms of accreditation experience, gender, race, ethnicity, professional expertise, and familiarity with the type of institution being surveyed.

b. For limited accreditation surveys

For schools undergoing limited accreditation surveys (not requiring a self-study nor completion of the full Medical Education Database), the survey team will typically consist of three members, including one or more medical educators who possess a doctoral-level graduate or professional degree and have held a faculty appointment at an LCME-accredited medical school for a period of at least five years. [Modifications approved by the LCME, June 2007.] As with full survey teams, one of the team members will be designated as chair and another as team secretary. When circumstances allow, the members of limited survey teams will include a representative of the LCME and an active medical practitioner.

c. Observers

Under special arrangements the survey team may include an observer from the U.S. Department of Education, a regional accrediting agency, or a state education authority. The dean of the program being reviewed will be asked to authorize the participation of the observer on the site visit. Senior staff members of the LCME's sponsoring organizations also may serve as observers as part of their orientation to the LCME and the accreditation process, upon approval by both Secretaries and the dean of the program involved. Distinguished international medical educators or representatives of other accrediting agencies may participate as observers upon request, and after approval by the LCME and the dean of the program involved. Guidelines for participation by observers are contained in Appendix A.

Site Visit Expenses

For surveys of accredited programs, the LCME pays the expenses of all team members except the Faculty Fellow, who is supported by his or her own institution. The program being evaluated is responsible for transporting the survey team to and from the hotel, and for arranging and funding any transportation to geographically separate campuses. For surveys of new or unaccredited programs, the school seeking accreditation is responsible for all site visit expenses.

The team secretary, if not a member of the LCME Secretariat staff, receives a stipend of $1500 from the LCME for a full survey, or $1000 for a limited survey. The LCME will also reimburse secretarial or clerical costs related to the production of the survey report, up to a maximum of $500 for a full survey report or $250 for a limited survey report.

F. Survey Reports

The reports of accreditation survey teams provide the principal source of information used by the LCME in making decisions regarding a program's accreditation status. The report of a full accreditation survey includes background information about the program, an executive summary of the survey team's principal findings (institutional strengths, noncompliance issues, areas in transition), detailed narrative about the program and its compliance with accreditation standards (including the program's performance with respect to student achievement), and an appendix that provides documentation to support the team's findings. Reports of limited surveys include background information, the team's assessment of the program's progress in addressing noncompliance issues and areas in transition, and supporting documentation.

Unless exceptional circumstances prevail, the draft report should be completed no more than eight weeks after the conclusion of a full accreditation survey, and six weeks in the case of a limited survey. The draft report is sent initially to the Secretariat for preliminary screening. After making any needed modifications based on Secretariat feedback, the team secretary then circulates the report to team members and the dean of the program being reviewed. The dean's role in reviewing the draft survey report is described more fully in the section of this document on "the accreditation survey process for complete medical education programs"."

The LCME will review the final report at its next regularly scheduled meeting, provided that its members have had at least two weeks to review the report prior to the meeting.

III. Conduct of LCME Meetings

A. Organization and Timing of Meetings

Regular Meetings

The LCME meets in regular sessions three times a year, early in the months of February, June, and October, unless the members agree to a different schedule. Regular meetings (including meetings of standing committees and ad hoc work groups) normally begin on Tuesday afternoon and conclude by mid-day on Thursday, or earlier if all necessary business has been conducted.

Special Meetings

The Co-Chairs, in consultation with the Secretaries, may call a special meeting to deal with any unusual issue(s) that cannot wait until the next scheduled regular meeting.

Informal Canvassing of Members; Formal Actions via Telecommunications, Electronic or Mail Ballots

The principal Secretary, upon authorization of the Co-Chairs, may informally canvass the members by mail, facsimile, electronic mail, telephone, teleconference, videoconference, or other medium to solicit their opinions on any issue. The results of such a canvass will be reported fully in the agenda of the next meeting.

Formal action may be taken without a meeting as follows:

Meeting Place

Meetings take place in the location of the principal Secretariat office for that year. For academic years beginning with an even number (e.g., 2004-05), meetings are held in Washington DC; for academic years beginning with an odd number (e.g., 2005-06), meetings take place in Chicago IL. Under special circumstances, the LCME may meet elsewhere in the U.S. or in Canada. Such a change in location must be approved by a majority vote of the LCME members.

Parliamentary Procedures and Quorum

All meetings of the LCME are conducted in accordance with the current edition of Sturgis' The Standard Code of Parliamentary Procedure. Quorum shall consist of nine of the seventeen voting members.

Attendance and Recusals

LCME members are expected to attend all meetings unless exceptional circumstances preclude their doing so. The Secretariat offices maintain a record of member attendance and report it to the sponsoring organizations when members are considered for reappointment. The minutes of each meeting include the list of attendees.

Members shall not vote on, and shall absent themselves from the discussion during consideration of, any school with which there could be a perceived conflict of interest (as described later in this document). Members who have participated in the site visit of a school being reviewed will not be assigned as a primary or secondary reviewer of the survey team's report, and their contributions to the discussion of the report should be limited to the following:

Site visit participants may not discuss their personal impressions of the program being reviewed, and should not introduce any anecdotal information or prior history not contained in the survey report.

Members who have participated in the site visit of a school being reviewed may vote on any related accreditation action, but shall not initiate or second any motions relating to an accreditation action for such schools.

Observers at LCME Meetings

U.S. and international medical educators, and individuals from other disciplines involved in higher education or the accreditation process, may request to attend a meeting of the LCME. Requests must be made in writing to the Secretariat, and require approval by the voting members of the LCME. Observers must agree in writing to hold all meeting materials and results of LCME discussions in strict confidentiality.

B. Accreditation Actions

Types of Accreditation Actions

When considering the accreditation status of a medical education program leading to the M.D. degree, the LCME may take any of the following actions:

Programs not currently holding LCME accreditation, as well as developing programs, may be granted an accreditation status as described elsewhere in this document. Programs already accredited by the LCME may have their accreditation status continued. In either of these cases the LCME may also require one or more follow-up activities (limited site visits, consultations, and/or progress reports), if it determines that the program is not in full compliance with all accreditation standards, or if areas in transition are identified whose final outcome could result in noncompliance with accreditation standards.

Accreditation Actions Subject to Appeal

Accreditation with probation, denial of accreditation, and withdrawal of accreditation are actions subject to appeal. Details of the appeal process are included in Appendix B. Such actions are not considered final until either (a) the program has indicated in writing its acceptance of the action, (b) the time for filing an appeal has lapsed, or (c) the appeal has been concluded and the school has been notified in writing of the outcome of the appeal.

Probation is an action based on the LCME's determination that an accredited program is not in substantial compliance with accreditation standards. Such a determination may be based on the LCME's judgment that the areas of noncompliance have seriously compromised the quality of the medical education program, or that the program has failed to make satisfactory progress in achieving compliance after having been granted ample opportunity to do so. Programs placed on probation retain their accredited status with all of the rights and privileges conveyed by such status, but are subject to withdrawal of accreditation if noncompliance issues are not satisfactorily addressed within a period of twenty-four months dating from the finalization of the decision as described above, unless the period of compliance is extended for good cause by the LCME. Any program placed on probation must promptly notify all enrolled students, those newly accepted for enrollment, and those seeking enrollment, of this accreditation status; failure to do so may result in withdrawal of accreditation.

Withdrawal of accreditation may occur when (a) there is documented evidence that an accredited program exhibits substantial deficiencies in compliance with LCME accreditation standards, and (b) the deficiencies are sufficiently serious, in the LCME's judgment, to raise concern whether graduates of the program are competent to enter the next stage of their training. Under normal circumstances, a program will have an opportunity to correct serious problems of noncompliance through the mechanisms of limited visits or probationary status before the LCME takes action to withdraw accreditation. However, rapid and precipitous deterioration in the quality of an educational program may be sufficient grounds for withdrawal of accreditation, whether or not a limited visit or probationary period has preceded the decision to withdraw accreditation.

Follow-up Activities

Any program that has not demonstrated full compliance with all accreditation standards, or that is engaged in activities or events whose outcome could result in noncompliance with accreditation standards ("areas in transition"), must provide evidence to the LCME in a timely manner that it has addressed such shortcomings or has made appropriate progress towards resolving them. The LCME will determine whether such evidence can be provided in a written progress report, or is best documented by on-site verification through a limited survey.

a. Progress Reports

A program may be asked to submit one or more progress reports, documenting steps taken to correct specific areas of noncompliance or the resolution of areas in transition. Progress reports are reviewed at the next regularly scheduled LCME meeting following their receipt.

If the requested documentation in the progress report is sufficiently complete, the LCME will take an accreditation action as described previously, with or without additional follow-up. If the documentation is inadequate (either because requested information was not provided or the information provided was insufficiently detailed or ambiguous) the LCME will reject the report and defer action pending receipt of additional or clarifying information.

b. Limited Surveys

Limited surveys are on-site evaluations conducted by ad hoc survey teams to verify the documentation indicating compliance with standards and resolution of areas in transition, and to assess the extent of a program's progress in achieving full compliance with accreditation standards. The findings of limited surveys and supporting documentation are compiled in a report to the LCME, and the dean is given an opportunity to review and comment on the draft report in the same manner as for full accreditation surveys. Approximately six months prior to the on-site evaluation, the Secretariat will provide the program with instructions regarding the documentation required for the limited survey.

A postprobation survey is a limited survey to assess compliance with accreditation standards and resolution of areas in transition subsequent to an LCME decision to place the program on probation. The survey team conducting a postprobation survey usually consists of three or four members, and will include one or more members of the LCME or its Secretariat staff. The Secretariat will provide the program with a summary of the documentation required for the postprobation survey approximately six months prior to the on-site evaluation.

A Secretariat visit is a limited survey conducted by Secretariat staff for purposes of fact-finding and assessment, but also to provide consultation and advice regarding LCME concerns about the program. The Secretariat visit team consists of two members of the LCME Secretariat staff. The Secretariat will provide the program with a summary of the documentation required for the Secretariat visit approximately six months prior to the on-site evaluation.

A Secretariat visit is not the same as a Secretariat consultation. The latter is a purely consultative activity between Secretariat staff and representatives of the program, and does not result in the preparation of a report for LCME review and action. Such consultations may be initiated at the request of the LCME (which would then be responsible for any associated expenses) or by the program (which would be responsible for associated expenses).

Prompt Correction of Deficiencies

Deficiencies in compliance with accreditation standards must be corrected promptly. The specified period for achieving full compliance may not exceed twenty-four months from the date of final action. Failure to achieve compliance within such time constitutes grounds for denial or withdrawal of accreditation unless the period for achieving compliance is extended, at the discretion of the LCME, for good cause shown. In determining whether good cause exists for an extension, the LCME may consider a number of factors, including but not limited to progress toward achieving full compliance, the complexity of changes that must be made, financial considerations, logistical considerations, and other circumstances internal or external to the medical school that might affect the time needed to come into full compliance.

Reporting of LCME Accreditation Actions

a. To Institutions

Within 30 days of any final LCME action on the reports of full or limited surveys, the principal Secretary will send (1) a Letter of Accreditation conveying the LCME action, and (2) a copy of the final survey team report, to the president or equivalent chief executive of the university, with a copy to the dean of the medical school. The Letter of Accreditation includes the LCME action, its findings regarding the program's strengths, areas of noncompliance with accreditation standards, and areas in transition, and any required follow-up. The Letter of Accreditation and final team report are held confidential by the LCME, but may be disclosed by the program at its discretion.

Within 30 days of any final LCME action on progress reports, the principal Secretary will send a letter to the dean of the medical school conveying the LCME action and any required follow-up.

b. To External Groups and the Public

The LCME Secretariat will notify the United States Secretary of Education of all actions taken at an LCME meeting within 30 days of the meeting. For actions subject to appeal (probation, denial of accreditation, withdrawal of accreditation), the notification to the Secretary of Education will be made no later than 30 days after the decision is made final. In decisions to deny or withdraw accreditation, the LCME will provide the Secretary of Education a summary of the facts of its review no later than 60 days after the decision is made final, along with any comments made by the program.

The Secretariat shall prepare and provide all necessary reports, petitions, and other documents required by the United States Department of Education for continued recognition of the LCME as the reliable authority for the accreditation of medical education programs leading to the M.D. degree. If an accredited program withdraws its accreditation status voluntarily or otherwise allows its accreditation status to lapse, the Secretariat will inform the Department of Education within 30 days of the date of withdrawal or lapse. [Modifications approved by the LCME, February 2007.]

Final decisions to deny or withdraw accreditation or to place a program on probation will also be reported to relevant licensing and accreditation bodies at the same time it notifies the institution or program of the decision, but no later than 30 days after the decision is made final. Such decisions will be conveyed to the public, by posting of the accreditation action on the LCME web site, within 24 hours of the notification to the institution or program. [Modifications approved by the LCME, June 2007.]

The current accreditation status of all accredited programs is posted publicly on the LCME web site (www.lcme.org) and updated as soon as possible after LCME meetings, and published annually in the medical education issue of the Journal of the American Medical Association (JAMA). Accreditation information made available to the general public includes the current accreditation status of a program and the date of its next accreditation survey, but does not include survey reports, correspondence with a program regarding its accreditation status, nor the basis for LCME actions regarding a program's accreditation status.

If a school makes a public disclosure of its accreditation status, the program must disclose that status accurately, and provide the name, address, and telephone number of the LCME Secretariat. Any incorrect or misleading statements about accreditation actions or accreditation status must be corrected or clarified by an official announcement or notification. Failure to make such a correction or clarification may result in reconsideration of the program's accreditation status. [Modifications approved by the LCME, February 2007.]

Responses to Actions of Other Oversight and Accrediting Bodies

The LCME will not grant or continue accreditation to programs within institutions where a state chartering authority or a regional accrediting agency has made a decision to (1) deny accreditation or preaccreditation, or a charter to operate, to the institution, or (2) to suspend, revoke, withdraw, or terminate the institution's accreditation or charter to operate. The LCME will reconsider the accreditation status of a program when the institution offering the program has been placed on probation by a regional accrediting agency or state chartering authority. In the latter case, if the LCME decides to grant or continue accreditation, it will provide to the Secretary of Education, within 30 days of its action, a thorough and reasonable explanation of its decision consistent with its standards. [Modifications approved by the LCME, June 2007.]

Circumstances That May Lead to an Unplanned Accreditation Review or Survey Visit

a. Changes in the balance of educational resources and class size

Accreditation is awarded to a program of medical education based on the judgment of the LCME that there is an appropriate balance between student enrollment and the total resources of the institution, including its faculty, physical facilities, patient population, and available funding. Prior notification to the LCME is required when an accredited program plans to modify the educational program or the resources supporting it, or to increase student enrollment, such that the balance between enrollment and resources would be substantially altered. Specific criteria regarding the magnitude of changes that require prior notification are available on the LCME web site. Changes in the balance between educational resources and class size may trigger a request for additional written information or an unplanned accreditation review or survey. [Modifications approved by the LCME, June 2007.]

b. Changes in ownership or governance, creation of new educational program tracks or campuses

The LCME also must receive prior notification of any significant changes in the ownership or governance of a medical education program (such as transfer of the program to the auspices of another university, merger of existing separate programs, or separation of the medical school from its existing parent institution). After reviewing the report of any such changes, the LCME will determine if any changes in the program's accreditation status or term are warranted, or if any additional follow-up is needed.

Prior notification is required when an accredited program plans to develop a new educational program track (alternate program of study within the curriculum) or provide instruction at a new branch campus. After reviewing the report of any such changes, the LCME will determine if any changes in the program's accreditation status or term are warranted, or if any additional follow-up is needed.

c. Validated complaints about educational program quality

If, after review of a valid complaint regarding educational program quality, the LCME determines that a program is not in full compliance with accreditation standards, it may decide to conduct a limited survey (see policies relating to complaints elsewhere in this document).

d. Willful deception

If, as part of the accreditation process, a program knowingly supplies false or misleading information to the LCME or its survey teams (including information provided in annual questionnaires, the database that accompanies a site visit, or progress reports), the LCME will reconsider the program's accreditation status and term, and determine any appropriate follow-up action. Similar action may result if a program knowingly fails to provide material information to the LCME or its survey teams, makes misleading or incorrect public statements or disclosures regarding its accreditation status, or fails to notify interested parties of an adverse accreditation action.

IV. Other Policies and Procedures

A. Development and Review of Accreditation Standards

Creation and Modification of Accreditation Standards

Suggestions for new standards or modifications to existing standards may come from any source, and most commonly originate from the medical education community (administrators, faculty, students) or from organizations interested in the improvement of medical education quality. Anyone who wishes to propose a new or revised standard should contact the Secretariat. The LCME conducts planned reviews of its accreditation standards over a five-year cycle. In planned reviews of accreditation standards, the LCME solicits feedback from appropriate stakeholders regarding the validity and clarity of the standards. In addition to planned reviews of accreditation standards, the LCME may also re-evaluate any existing standard or standards when circumstances warrant.

Minor modifications to existing standards (i.e., changes to clarify the intent or focus of the standard by rewording it or adding an annotation) are developed by the Subcommittee on Standards for consideration by the Executive Committee and the LCME, but do not require sponsor approval or public hearing. Substantive changes to existing standards (which impose new or additional requirements on programs to achieve compliance) must undergo sponsor approval and public hearing, as described in Appendix C, before being adopted by the LCME.

Procedures for Changing Accreditation Standards

Any changes to accreditation standards are presented first to the Executive Committee for consideration. If the Executive Committee finds merit in the proposal, the standard is referred to the Subcommittee on Standards for further action. The Subcommittee on Standards will evaluate the proposal to determine if existing standards already address the issue, or if annotation of existing standards is needed. If existing standards do not address the issue, the subcommittee will develop draft language and any necessary annotations and submit the new or revised standard to the Executive Committee for discussion and action.

The Executive Committee will either refer the draft standard back to the subcommittee for further refinement or forward it to the LCME for formal approval. New or substantially revised standards approved by the LCME then undergo a process of sponsor review and public hearing, as described in Appendix C. New or revised standards that have successfully undergone the sponsor approval and public hearing process are published with an effective date in the document Functions and Structure of a Medical School.

B. Conflicts of Interest

To avoid actual or perceived conflicts of interest, LCME members, staff, and surveyors must agree in writing to abide by the following policies:

a. Site Visits and Accreditation Decisions

No LCME Representative (defined as a member of the LCME, its staff, or an on-site survey team) will participate in a site visit, nor in discussions or voting at LCME meetings, if the program being visited or discussed is:

1. One in which the Representative or an immediate family member (defined as a spouse, life partner, child, parent, or sibling) has been connected as a student, graduate, faculty member, administrative officer, staff member, employee, or contracted agent within the past five years.

2. One in which the Representative or an immediate family member has interviewed for employment within the past two years.

3. Located in the same state as the program or institution of the Representative, or in such close geographic proximity that the programs or institutions involved can reasonably be considered as competing with each other for financial advantage (for example, in the operation of hospitals or clinics operated by the programs).

4. Part of a university system where the Representative is employed.

5. Engaged in substantial cooperative or contractual arrangements with the program or institution of the Representative or an immediate family member.

6. One which has engaged the Representative or an immediate family member as a paid consultant within the past five years on matters such as program development or evaluation, organizational structure or design, and institutional management or finances. Provision of short-term educational services (such as guest lectures) is not considered consulting that poses a conflict of interest.

7. One in which the Representative or an immediate family member has any financial, political, professional, or other interest that may conflict with the interests of the LCME.

8. One in which the Representative believes that there may be a conflict due to other circumstances, such as participation in accreditation or review of the program for other agencies, close personal relationships with individuals at the program, etc.

9. One in which the program has reason to believe, and can document to the satisfaction of the principal Secretary, that the participation of the Representative could be unfairly prejudicial.

b. Consultations

No LCME Member will act as a paid or unpaid external consultant on LCME accreditation matters to any program or institution subject to LCME accreditation, unless such consultation is authorized by the LCME. LCME members and staff will not provide consultation on LCME accreditation matters to any program or institution subject to LCME accreditation for a period of two years after completion of their service with the LCME, unless authorized by the LCME. [Modifications approved by the LCME, June 2007.]

C. Data Collection, Research, and Confidentiality

All materials provided by schools in conjunction with accreditation surveys, including the Medical Education Database, Institutional Self-Study Summary Report, and any other relevant documents, will be retained for the two most recent accreditation cycles. Reports of accreditation surveys, progress reports, records of LCME actions, correspondence with individual medical schools, and minutes and agendas of all LCME meetings will be retained indefinitely. [Modifications approved by the LCME, February 2007.]

All medical schools providing LCME-accredited medical education programs are required to complete annual questionnaires that are administered by the Association of American Medical Colleges and the American Medical Association under the auspices of the LCME. The Association of American Medical Colleges administers questionnaires regarding medical school finances and student financial aid, while the American Medical Association surveys schools regarding their organization and curriculum. These questionnaires are reviewed annually by the Secretariat to maintain consistency with other LCME data collection instruments. Data derived from the LCME questionnaires, as well as data from other sources, are compiled into an annual statistical summary for each school, which is used by the LCME for monitoring medical education programs in the interval between accreditation surveys.

Summary data from the LCME questionnaires are published annually in an article in the Journal of the American Medical Association on the state of undergraduate medical education in the U.S. Data from the questionnaires may also be used by the sponsoring organizations to provide benchmarking reports and other activities for improving medical education quality. Information contained in the questionnaires conforms to the confidentiality requirements of the sponsoring organizations, and may not be shared with other organizations without LCME authorization.

All information compiled in preparation for accreditation surveys or collected on site, including the contents of the Medical Education Database, the program's self-study summary report, and correspondence regarding the program's prior accreditation history, is held in strict confidence by the Secretariat. Survey team members must sign a confidentiality statement agreeing to abide by the LCME's confidentiality requirements as a condition for participating in the site visit. All information received by the LCME that relates to a school's accreditation status (including survey reports and progress reports) is also treated as confidential data, and LCME members and staff must also sign a confidentiality statement as a condition for participating in LCME meetings and related activities.

LCME staff may conduct research based on confidential information contained in Medical Education Databases, self-study documents, and survey and progress reports. Neither the source documents used for such research nor the results of such research may be shared or made available to other individuals or organizations (including staff of the LCME's sponsoring organizations) unless authorized by the LCME. Data obtained from annual LCME questionnaires may be shared or made available to other individuals or organizations to the extent that confidentiality requirements and data-sharing agreements of the LCME's sponsoring organizations permit.

D. Complaints and Third-Party Comments

Complaints and Third-Party Comments about Program Quality

The LCME will consider complaints about program quality which, if substantiated, would represent partial or substantial noncompliance with one or more of its accreditation standards. It will not, however, intervene on behalf of a complainant to achieve redress of grievances, with regard to issues such as admission to medical school, dismissal or disciplinary actions involving students or faculty, or faculty appointment or advancement. Complaints may come from any source. All complaints must be submitted in writing to the Secretariat. Anonymous complaints will not be considered.

The LCME welcomes third-party comment about programs scheduled for an accreditation survey for renewal or granting of accreditation. Dates of upcoming surveys are listed on the LCME web site. Like complaints, third-party comments must be submitted to the Secretariat in writing and will not be considered if they are submitted anonymously. If the comments involve potential noncompliance with accreditation standards, they must be received by the Secretariat no later than three months before the date of the accreditation survey; comments alleging noncompliance received less than three months before the date of a survey will be treated as a complaint about program quality.

The Secretariat will conduct an initial evaluation of any complaint about program quality to determine whether it represents potential noncompliance with accreditation standards. Any third-party comments which relate to possible noncompliance with LCME accreditation standards will be similarly evaluated by the Secretariat. In either case, the program's dean will receive a copy of the complaint or comment and will be given an opportunity to respond in writing. For third-party comments received at least three months before the date of a program's scheduled accreditation survey, the issue(s) and the program's response will be evaluated by the team conducting the on-site survey. Complaints, and third-party comments received less than three months before an on-site survey, will be reviewed along with the program's response by an ad hoc Subcommittee on Complaints appointed by the Secretariat and Co-Chairs of the LCME. Details of these procedures are included in Appendix D. The complainant will not be informed of the result of any such review. [Modifications approved by the LCME, February 2006.].

Complaints about LCME Accreditation Standards, Policies, Procedures, and Operations

Complaints about the LCME's accreditation standards, policies, procedures, or operations are reviewed by the Executive Committee of the LCME. Such complaints must be submitted in writing to the Secretariat and will not be consider if they are submitted anonymously. The Executive Committee will present its findings and any recommended actions to the LCME at the next regularly scheduled meeting occurring at least 60 days after the complaint is received. The complainant will be advised in a timely manner of the LCME's response to the complaint.

Appendix A

Observers on LCME Survey Visits

Observers from the United States Department of Education, Regional Postsecondary Accrediting Agencies, and State Education Departments

The LCME annually notifies the appropriate regional and state accreditation agencies of scheduled site visits to schools within their jurisdictions. Such agencies (e.g., the Commission on Accreditation of the Middle States Association of Colleges and Schools, the New York State Department of Education) sometimes request permission to appoint an observer to gather information by participating in survey team meetings with medical school administrators, faculty members, and students. The U.S. Department of Education may also request permission to designate an observer as part of their review process for federal recognition of the LCME. The principal Secretary may appoint such observers after receiving written consent from the dean of the program being reviewed. As a rule, such observers may participate in the discussions during meetings with medical school parties to the extent that the business of the LCME survey team is not delayed or compromised. Observers are not to solicit the findings or conclusions of LCME surveyors.

The program being reviewed should send a copy of its LCME self-study summary report and Medical Education Database to the observer. Generally, the observer will attend the LCME team's pre-survey caucus and the meetings of surveyors with medical school administrators, faculty members, and students. The observers do not attend the survey team's evening working sessions or the exit conferences with the dean and president. Draft survey reports are not to be shared with regional/state accrediting agencies or their representatives. Schools may provide the appropriate agencies with copies of final survey reports and letters of accreditation from the LCME.

Observers from U.S. or International Institutions or Organizations, and from Staff of the LCME's Sponsoring Organizations

Individuals from appropriate U.S. or international organizations with an interest in the LCME process who wish to participate in a survey visit must contact the LCME Secretariat in writing. The request must include the reason for participating and the individual's role in medical education or program evaluation. The request will be considered by the LCME at its next regularly-scheduled meeting.

If the LCME grants the request, the principal Secretary will identify a school where the observer may be included on the survey team. Permission for the observer to participate must be obtained from the school. The observer may be involved in all aspects of the survey visit but must agree in writing to hold confidential all information obtained during the visit.

Staff from the sponsoring organizations of the LCME or the CACMS may participate as observers on a site visit with the consent of the dean of the institution being reviewed and the approval of both LCME Secretaries.

Appendix B

Appeal Procedure for Actions Affecting Accreditation

Actions of the LCME that are Subject to Appeal

The following actions by the LCME affecting accreditation are subject to appeal:

a. Assignment of probationary status;

b. Withdrawal of accreditation; or

c. Denial of accreditation.

The appeal shall be limited to the time and circumstances that triggered the LCME action (e.g., a survey visit, progress report, etc) and shall be based solely on the information contained in the final survey report. Descriptions of changes made since that time will not be considered.

Notice of LCME Action

Upon a finding that a program of medical education is not in substantial compliance with the LCME's published accreditation standards, and imposition of an initial action negatively impacting the program's accreditation status, the LCME Secretariat shall promptly notify the sponsoring institution in writing of the action and of the specific areas of noncompliance that support the imposition of the action. The Secretariat also shall inform the sponsoring institution of the right to appeal.

Notice of Appeal

If it wishes to appeal the LCME's decision, the sponsoring institution must notify the LCME Secretariat within thirty (30) calendar days from the date of receipt of the notice of the LCME action. Such Notice of Appeal must be addressed to the LCME Secretariat and must contain a concise statement of why the institution believes that the LCME's action was improper.

If no written request for an appeal is received by the LCME within thirty (30) days, the LCME's initial action shall constitute final action by the LCME.

The Appeal Process

The appeal process consists of two steps: (1) review by an independent ad hoc review committee and (2) LCME review with or without a hearing. In order to expedite the process, the institution may waive review by an independent ad hoc review committee by providing a written waiver to the LCME Secretariat. At the end of the appeal process, the LCME will make a final decision whether to affirm, modify, or reverse its initial accreditation decision.

Step 1: Review by an Independent Review Committee

The first step in the appeal process is review by an ad hoc Review Committee, which will be advisory to the LCME. The Review Committee shall be appointed by the LCME Secretariat in consultation with the Co-Chairs and shall consist of three individuals who are former LCME members or who otherwise meet the qualifications for membership on the LCME. No person shall be included on a Review Committee for a given program if he or she has participated in a survey visit that triggered the LCME action; has reviewed recent survey findings, progress reports, or other LCME findings or conclusions regarding that program on behalf of the LCME; or has a conflict of interest as determined under the LCME Conflict of Interest Guidelines.

Once the Review Committee has been established, neither the sponsoring institution nor any member of the LCME shall contact any member of the Review Committee concerning the matter under appeal.

The LCME Secretariat shall forward to each of the members of the Review Committee the following materials, which shall constitute the Review Record: a complete file of all documents concerning the program that were available to the LCME and upon which the LCME relied in the action that is the subject of the appeal.

The Review Committee shall make one of the following recommendations to the LCME:

a. Affirm the initial LCME action; or

b. Recommend that the LCME reconsider its action.

If the Review Committee determines that there is no reason to alter the initial LCME action, it shall recommend that the action be affirmed. If the Review Committee determines that the LCME's action is not supported by the evidence, or was not made in substantial accordance with LCME policies and procedures, it shall recommend reconsideration of the action. The Review Committee shall forward a written report of its recommendation, and the reasons therefore, to the LCME. The Review Committee process, including the filing of the report with the LCME, shall be completed within sixty (60) days from the time that the institution files its decision to appeal.

Step 2: Hearing before the LCME

The second step of the appeal process is a hearing before the LCME. No person shall be present for or participate in a hearing if he or she has a conflict of interest as determined under the LCME Conflict of Interest Guidelines.

Timing of LCME Hearing

The LCME Secretariat shall schedule the appeal hearing for a regularly scheduled LCME meeting that will occur more than sixty (60) calendar days after receipt of the report of the Review Committee.

The LCME Secretariat shall notify the institution in writing of the date, time and place of the hearing. The notice shall be provided at least forty-five (45) calendar days prior to the hearing. The notice shall advise the institution that it:

(1) may send representatives to appear before the LCME;

(2) may be represented by legal counsel; and

(3) may submit a written response to the LCME's cited areas of noncompliance. Such response must be based solely on the information contained in the final survey report.

The institution's written intent to send representatives to appear before the LCME, the names of the representatives and, if any, the legal counsel who will attend the hearing, must be received by the LCME Secretariat no later than twenty-one (21) calendar days before the scheduled date of the hearing.

The Secretariat shall send to each member of the LCME who shall participate in the hearing the following materials, which shall constitute the Appeal Record: the Review Record and the Review Committee's report and recommendation.

Conduct of the Hearing Before the LCME

The hearing before the LCME shall be chaired by one of the LCME Co-Chairs.

The hearing will be limited to a consideration of the time and circumstances that triggered the initial LCME decision. Descriptions of changes made since that time shall not be considered.

While strict adherence to the formal rules of evidence shall not be required, irrelevant or unduly repetitious statements may be ruled out of order. The hearing shall follow the following general format:

a. Introductory statement of the Chair.

b. Oral presentation by the institution (one hour).

c. Questions by LCME members and staff.

d. LCME executive session (15 minutes).

e. Additional questions by LCME members and staff.

f. Closing statement by the institution (15 minutes).

g. Adjournment.

A record of the hearing shall be kept by a certified court reporter.

If the institution, without good cause, fails to appear or fails to advise the LCME Secretariat in writing more than five (5) calendar days before the scheduled date of the hearing that it will not appear, the LCME may elect to notify the institution that no further opportunity for a personal appearance will be provided.

Decision of the LCME

At the conclusion of the hearing, the LCME shall meet in executive session to review the proceedings and to reach a decision. The LCME shall consider the Appeal Record and the information presented during the hearing. The LCME shall determine whether each of the cited areas of noncompliance with LCME accreditation standards is supported by substantial credible evidence.

The LCME shall determine by majority of those members present whether substantial evidence supports the existence of the cited areas of noncompliance with accreditation standards, and whether the initial LCME action should be affirmed, modified or reversed. Such determination shall constitute final action by the LCME.

The LCME Secretariat shall notify the institution in writing of the LCME decision, including the reasons therefore, within thirty (30) calendar days after the hearing.

LCME Review Without A Hearing

An institution may inform the LCME in writing that it does not wish to appear before the LCME. In such event, the LCME will consider the accreditation status of the program at the next regularly-scheduled meeting. The LCME shall rely on the Appeal Record for information. The LCME shall determine by majority of those members present whether to affirm, modify or reverse its initial action. The LCME Secretariat shall notify the institution in writing of the LCME's decision, including the reasons therefore, within thirty (30) calendar days after the LCME meeting.

Such decision shall constitute final action by the LCME.

Notification of Accreditation Status

The prior accreditation status of a program shall remain in effect until the LCME's action becomes final pursuant to the provisions of this APPENDIX B.

If the LCME's final action is to assign probationary status, withdraw accreditation, or deny or refuse to consider an institution for accreditation, the program shall be required to notify all students enrolled, those accepted for enrollment, and those seeking enrollment. The program shall provide the LCME Secretariat with a copy of such notification promptly after receiving notice of the final action by the LCME assigning probationary status, withdrawing accreditation, or denying or refusing to consider for accreditation. The program also shall notify others, on request, of its accreditation status.

Responsibility for the Cost of Appeals

The costs of the Review Committee's review and the appeal conducted by the LCME shall be allocated in the following manner:

a. The LCME shall bear all of the administrative and meeting costs for the appeal to the LCME, including the costs of the Review Committee.

b. The institution or program appealing an LCME decision shall bear all of the costs involved in the development and presentation of its appeal and in the travel and other expenses of its representatives present at any hearing.

c. The LCME shall bear the cost of transcribing the hearing. The sponsoring institution shall be required to pay for any copies of the transcript it desires.

Notice and Filings with the LCME Secretariat

Whenever, under any of the provisions of this APPENDIX B, there is a requirement for a written notice or request to the LCME Secretariat, said notice or request shall be sent to both LCME Secretaries at the following addresses:

Canadian schools also should notify:

Appeals by Canadian Institutions [Approved by the LCME, June 2006]

If a Canadian program is subject to an appealable action taken by either the LCME or CACMS but not by both agencies, the appeal procedure of the accrediting body taking such action will apply. Because the LCME and CACMS meet at different times, there may be an interval when the program does not know if both organizations have taken the same appealable action. Under such circumstances, the program should follow the appeal procedure and timetable for the accrediting body which has already imposed an accreditation action subject to appeal. Should the other accrediting body also impose the same accreditation action subject to appeal when it reviews the program, the procedural modifications described below will apply, and the Secretariats of the two accrediting bodies will make appropriate adjustments in the timetables for the appeal process to ensure that the program has at least as much time for each step of the appeal process as required in the preceding sections.

When a Canadian program is subject to an appealable action taken by both the LCME and CACMS, the procedures described in this Appendix will apply with the following exceptions:

a. Notification of the action will be communicated to the sponsoring institution by both the LCME and CACMS.

b. Any notification by the sponsoring institution of its intent to appeal must be made to CACMS, with a copy to the LCME, within thirty calendar days from the date of receipt of the notice of the LCME/CACMS action.

c. The Independent Review Committee will consist of two members appointed by the CACMS Secretary in consultation with the chair of CACMS, and one member appointed by the LCME Secretariat in consultation with the co-chairs of the LCME.

d. Any hearing of the appeal will take place before the membership of both the LCME and CACMS.

e. Upon conclusion of the hearing, or in the case of an appeal without hearing, the LCME and CACMS will make separate and independent determinations to affirm, modify, or reverse the initial action.

Appendix C

Procedures for Changing Accreditation Standards

Requests for new or revised accreditation standards may arise from any source. Any requests for new standards or modification of existing standards should be sent to the LCME Secretariat, and will be reviewed initially by the Executive Committee of the LCME. If a proposed standard or standard change is deemed to have merit it is referred to the Subcommittee on Standards for further action.

The Subcommittee on Standards develops draft language and any needed annotations and forwards them to the Executive Committee for consideration. Technical amendments to standards (minor changes in wording that do not alter the content or requirements of the standard) and annotations to standards also are developed by the Subcommittee when appropriate.

After review and deliberation by the Executive Committee, proposed changes in standards are forwarded to the LCME. Technical changes to existing standards may be approved and adopted immediately by the LCME. New standards, as well as revisions to existing standards which alter their content or requirements for compliance, must be approved by the LCME, the CACMS, and their respective sponsoring organizations, and undergo a public hearing before they can be finally adopted by the LCME.

LCME recommendations on such substantive standard changes are submitted to the Executive Council of the Association of American Medical Colleges, the Council on Medical Education of the American Medical Association, and, in Canada, to the Committee on Accreditation of Canadian Medical Schools, to the Association of Faculties of Medicine of Canada, and the Canadian Medical Association. These bodies review the recommendations and return to the LCME their notice of endorsement, disapproval, or any proposed amendments to the changes.

If the recommendations are not approved by the sponsoring organizations, CACMS, or its sponsors, the LCME will revise the standard and resubmit to the other organizations for approval, or withdraw the standard from consideration. If the recommendations are approved, the LCME will reconcile any proposed amendments from the sponsoring organizations and prepare a final version for consideration at a public hearing.

Announcements of the public hearing are disseminated through the LCME web site and by publication in various AMA and AAMC media. The public hearing usually is held at the time of the annual or interim meeting of the AMA or at the time of a meeting of the AAMC or its Executive Council. Designated LCME members (usually one or both co-chairs), supported by the Secretariat professional staff, preside at public hearings. Comments made during a hearing are recorded or transcribed and, together with written documentation submitted prior to or during the hearing, constitute the hearing record.

If there is substantial agreement in the public hearing, the proposed changes are considered for final adoption at the next regularly scheduled LCME meeting. If the public commentary reflects substantial disagreement, the LCME will direct the Secretariat to prepare a revised draft for reconsideration by the LCME or will withdraw the standard. Should the LCME approve a version appreciably different from that originally endorsed by the sponsors, the amended version is sent back to the sponsoring organizations for approval. Upon the approval of the sponsoring organizations, the amended version will be subject to public hearing.

Any new or revised standard adopted by the LCME will be published on its web site and in the document Functions and Structure of a Medical School, along with the effective date for the standard.

Appendix D

Procedures For Handling Complaints or Third-Party Comments About Program Quality

Any person concerned about the quality of an undergraduate medical education program accredited by the Liaison Committee on Medical Education (LCME) may contact the LCME Secretariat to discuss lodging a complaint. Only those complaints will be investigated which, if substantiated, may constitute noncompliance with accreditation standards. The LCME will not intervene on behalf of an individual complainant regarding, for example, matters of admission, appointment, promotion, or dismissal of faculty or students.

Submitting a Complaint or Comment

Complaints and third-party comments must be made in writing, and may come from any source. Anonymous submissions will not be considered. Third-party comments relating to possible noncompliance with accreditation standards, if received at least three months before a scheduled accreditation survey, will be reviewed by the survey team; third-party comments received after that time, and complaints not associated with an impending survey, will be reviewed by an ad hoc subcommittee of the LCME.

The written complaint or comment should contain as much information and detail as possible about the circumstances that form the basis of the complaint or comment. If possible, the complainant should cite the relevant accreditation standards relating to the complaint. If the complaint or comment indicates circumstances which, if substantiated, would indicate areas of noncompliance with accreditation standards, the LCME Secretariat will contact the author (1) to obtain additional documentation or corroboration, if needed, and (2) to request a signed release form. If the complainant does not comply with either request, the file will be closed and no further action will be taken.

The LCME shall attempt to maintain the confidentiality of complaints and comments and any corroborating material. However:

· Any information about a program or school may be released to the dean of the medical school, members and staff of the LCME, their respective attorneys, and other persons authorized by the dean, required by law or necessity, at the discretion of the LCME, to fully investigate the complaint.
· The complainant and any corroborators will be required to sign an authorization to release the written complaint or comment and corroborating materials to the dean of the medical school, members and staff of the LCME, their respective attorneys, and appropriate outside parties.
· The complainant and any corroborators also will be required to authorize the school to release any information deemed necessary by the LCME.

Investigating a Complaint or Comment

The LCME Secretariat will make an initial determination of whether the complaint or comment contains issues relating to the program's compliance with accreditation standards.

If the LCME Secretariat determines that the complaint or comment does raise such issues, the Secretariat will contact the dean, including the letter of complaint or comment and corroborating information, and citing the information that the dean should provide in response. A response from the dean will ordinarily be requested within 30 days.

Review of Complaint or Comment

Third-party comments (including any corroborating materials) received no less than three months before a scheduled accreditation survey, and the dean's response, will be forwarded to the survey team for investigation as part of their on-site evaluation of the program. Any findings of the team regarding the comment will be included as part of the survey report.

Complaints not submitted in conjunction with an impending site visit, and third-party comments received less than three months before a scheduled accreditation survey, together with corroborating materials and the response from the dean, will be reviewed by an ad hoc Subcommittee on Complaints that is appointed by the Secretariat and the co-Chairs.

The subcommittee will review the complaint or third-party comment, and any response from the school, and present a written report of its findings and recommendations to the LCME for discussion at the next regularly scheduled LCME meeting. The LCME will make a final determination, including the nature and timing of any required follow-up, and will direct the Secretariat to notify the dean of its decision. [Modifications approved by the LCME, February 2006.]

Response to Complainant

The complainant will be notified whether an investigation will be undertaken or not. The complainant will not be informed of the result of any such investigation. [Modifications approved by the LCME, February 2006.]

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Revised 15 October 2007
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