1. STANDARD 1: LEADERSHIP AND ADMINISTRATION

2. Standard 1 Team Members  Team Lead: Ken Roberts Vice Dean for Academic and Community Partnerships, ESF COM  Team Support:Kim Noe Administrative Manager, ESF COM

3. Standard 1 Team Members  Ted Chauvin, Clinical Assistant Professor, ESF COM  Jeff Collins, Physician, Providence  Marcos Frank, Interim Chair, Biomedical Sciences Dept. ESF COM  Dale Hoekema, Medical Affairs, Chief Medical Office, Intensivist  Craig Parks, Professor, Department of Psychology  Sandy Norris, Director Medical Education, Swedish Hospital  Joanne Roberts, Chief Medical Officer, Physician, Everett  John Roll, Sr. VC Academic Affairs & Research, WSU Spokane and Vice Dean for Research ESF COM  Bryan Slinker, Dean, WSU College of Veterinary Medicine  Steve Sylvester, Associate Professor, Molecular Bioscience Dept., Vancouver  James Zimmerman, Vice Dean for Administration, Accreditation and Finance – Chief Operating Officer, ESF COM

4. Time Line  February 2016 – LCME granted candidate status  May 2016 – Standard 1 work completed and metrics set for LCME site visit  June 26-29, 2016 – LCME accrediting team site visit  October 2016 – This is the date of an LCME meeting at which they may act on WSU’s request for preliminary accreditation.  Only when preliminary accreditation is granted can we begin student recruitment  Fall 1017 – We hope to matriculate first cohort of students.

5. Team Member Roles  Provide expertise, content and direction for specific standard elements  Contribute to update of DCI document  Contribute to the ESFCOM Standards-based Continuous Quality Leadership initiative  This is ongoing, bidirectional function of committee  Participate in the LCME site visit preparation, and perhaps in the site visit.

6. Standards-based Continuous Quality Leadership SBCQL Initiative Goals  Real-time compliance status and performance trends  Identification of opportunities to achieve excellence at reasonable cost  Adverse trends always addressed using CQI methods  DCI documents always current and available  Ensure continuous compliance with LCME standards

7. Metrics Standard 1.1: Strategic Planning and Continuous Quality Improvement  A medical school engages in ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve programmatic quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards.

8. Policy Standard 1.2: Conflict of Interest Policies  A medical school has in place and follows effective policies and procedures applicable to board members, faculty members, and any other individuals who participate in decision-making affecting the medical education program to avoid the impact of conflicts of interest in the operation of the medical education program, its associated clinical facilities, and any related enterprises.

9. Faculty Standard 1.3: Mechanisms for Faculty Participation  A medical school ensures that there are effective mechanisms in place for direct faculty participation in decision-making related to the medical education program, including opportunities for faculty participation in discussions about, and the establishment of, policies and procedures for the program, as appropriate.

10. Clinical Affiliations Standard 1.4: Affiliation Agreements  In the relationship between a medical school and its clinical affiliates, the educational program for all medical students remains under the control of the medical school’s faculty, as specified in written affiliation agreements that define the responsibilities of each party related to the medical education program. Written agreements are necessary with clinical affiliates that are used regularly for required clinical experiences; such agreements may also be warranted with other clinical facilities that have a significant role in the clinical education program. Such agreements provide for, at a minimum the following:  The assurance of medical student and faculty access to appropriate resources for medical student education  The primacy of the medical education program’s authority over academic affairs and the education/assessment of medical students  Specification of the responsibility for treatment and follow-up when a medical student is exposed to an infectious or environmental hazard or other occupational injury  The shared responsibility of the clinical affiliate and the medical school for creating and maintaining an appropriate learning environment

11. Bylaws Standard 1.5: Bylaws  A medical school promulgates bylaws or similar policy documents that describe the responsibilities and privileges of its administrative officers, faculty, medical students, and committees.

12. Regional Accreditation Standard 1.6: Eligibility Requirements  A medical school ensures that its medical education program meets all eligibility requirements of the LCME for initial and continuing accreditation, including receipt of degree-granting authority and accreditation by a regional accrediting body by either the medical school or its parent institution.

13. Actions Steps  Review Standard 1 of the DCI as submitted  Prepare a list of open items  Determine priority to complete each  Identify resources for each  For each element, identify how to measure compliance

14. Performance Measures

15. Developing Metrics and Measurements Open SharePoint Standard 1 CQL:  Std 1 standards and measurements Excel file  https://medicine.spokane.wsu.edu/accreditation/_layouts /15/start.aspx#/ https://medicine.spokane.wsu.edu/accreditation/_layouts /15/start.aspx#/

16. Questions? Open Discussion

17. List of Open Items  Finalize College of Medicine strategic plan (1.1)  Develop process for monitoring strategic plan (1.1)  Design Continuous Quality Leadership process (metrics and measurements) for maintaining accreditation standards (1.1)  Prescribe the courses of instruction for the medical students and publish in catalog (1.2)  Finalize Conflict of Interest policy (1.2)  Finalize faculty manual/bylaws with provision of state ethics law and standing committees/membership (1.2)  Form permanent standing departmental committees (1.3)  Draft committee selection policy (1.3)  Update COM website to include DCI referenced items (1.3)  Finalize affiliation agreements (1.4)  Finalize bylaws with faculty senate approval (1.5)