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Improvement through accreditation

Penn State College of Medicine is preparing for its 2025-26 re-accreditation from the Liaison Committee on Medical Education (LCME). LCME accreditation is a voluntary, peer-reviewed process of quality assurance that determines whether the medical education program meets established standards. This process also fosters institutional and programmatic improvement. Faculty, staff and students all take part in this extensive process.

The Basics of Reaccreditation

  • The LCME is jointly sponsored by the Association of American Medical Colleges and the Council on Medical Education of the American Medical Association. The AAMC and the AMA each appoint an LCME Co-Secretary (known jointly as the Secretariat) and maintain accreditation offices in Washington, D.C., and Chicago, respectively.

    Learn more at LCME.org

  • Accreditation is a process of quality assurance in postsecondary education that determines whether an institution or program meets established standards for function, structure, and performance.

    The accreditation process also fosters institutional and program improvement.

    Accreditation seeks to answer:

    • Does the program have clearly established mission, goals and institutional learning objectives?
    • Are the program’s curriculum and resources organized to meet its mission, goals and objectives?
    • What is the evidence that the program is achieving its mission, goals and objectives and is likely to continue to achieve them?

  • Steps toward reaccreditation

    Collecting the data (completing the Data Collection Instrument)

    An institutional self-evaluation (self-study) based on the DCI information (12 accreditation standards)

    An on-site evaluation (survey visit) by a survey team of external peer experts (2025-2026)

    The review of the survey team’s findings by the LCME Board (3 to 5 months later)

    The LCME’s determination of the program’s accreditation status and any necessary follow-up

    Collecting the data (completing the Data Collection Instrument)

    An institutional self-evaluation (self-study) based on the DCI information (12 accreditation standards)

    An on-site evaluation (survey visit) by a survey team of external peer experts (2025-2026)

    The review of the survey team’s findings by the LCME Board (3 to 5 months later)

    The LCME’s determination of the program’s accreditation status and any necessary follow-up

    • 12 standards with multiple sub-standards (93 elements) indicate the guidelines and expectations for medical schools.
    • To assess compliance they require data about:
      • Our Organizational Structure
      • Learning Environment
      • Mission And Strategic Planning
      • Admissions Processes
      • By-laws And Policies
      • Faculty And Staff (Education/Research)
      • Curriculum
      • Resources (Money, Space, People)

  • LCME uses 12 standards for accreditation of medical education programs:

    1. Mission, Planning, Organization, and Integrity
    2. Leadership and Administration
    3. Academic and Learning Environments
    4. Faculty Preparation, Productivity, Participation, and Policies
    5. Educational Resources and Infrastructure
    6. Competencies, Curricular Objectives, and Curricular design
    7. Curricular Content
    8. Curricular Management, Evaluation, and Enhancement
    9. Teaching, Supervision, Assessment, Student/Patient Safety
    10. Medical Student Selection, Assignment, and Progress
    11. Medical Student Academic Support, Career Advising, and Educational Records
    12. Medical Student Health Services, Personal Counseling, and Financial Aid Services

The LCME is jointly sponsored by the Association of American Medical Colleges and the Council on Medical Education of the American Medical Association. The AAMC and the AMA each appoint an LCME Co-Secretary (known jointly as the Secretariat) and maintain accreditation offices in Washington, D.C., and Chicago, respectively.

Learn more at LCME.org

Accreditation is a process of quality assurance in postsecondary education that determines whether an institution or program meets established standards for function, structure, and performance.

The accreditation process also fosters institutional and program improvement.

Accreditation seeks to answer:

  • Does the program have clearly established mission, goals and institutional learning objectives?
  • Are the program’s curriculum and resources organized to meet its mission, goals and objectives?
  • What is the evidence that the program is achieving its mission, goals and objectives and is likely to continue to achieve them?

Steps toward reaccreditation

Collecting the data (completing the Data Collection Instrument)

An institutional self-evaluation (self-study) based on the DCI information (12 accreditation standards)

An on-site evaluation (survey visit) by a survey team of external peer experts (2025-2026)

The review of the survey team’s findings by the LCME Board (3 to 5 months later)

The LCME’s determination of the program’s accreditation status and any necessary follow-up

Collecting the data (completing the Data Collection Instrument)

An institutional self-evaluation (self-study) based on the DCI information (12 accreditation standards)

An on-site evaluation (survey visit) by a survey team of external peer experts (2025-2026)

The review of the survey team’s findings by the LCME Board (3 to 5 months later)

The LCME’s determination of the program’s accreditation status and any necessary follow-up

  • 12 standards with multiple sub-standards (93 elements) indicate the guidelines and expectations for medical schools.
  • To assess compliance they require data about:
    • Our Organizational Structure
    • Learning Environment
    • Mission And Strategic Planning
    • Admissions Processes
    • By-laws And Policies
    • Faculty And Staff (Education/Research)
    • Curriculum
    • Resources (Money, Space, People)

LCME uses 12 standards for accreditation of medical education programs:

  1. Mission, Planning, Organization, and Integrity
  2. Leadership and Administration
  3. Academic and Learning Environments
  4. Faculty Preparation, Productivity, Participation, and Policies
  5. Educational Resources and Infrastructure
  6. Competencies, Curricular Objectives, and Curricular design
  7. Curricular Content
  8. Curricular Management, Evaluation, and Enhancement
  9. Teaching, Supervision, Assessment, Student/Patient Safety
  10. Medical Student Selection, Assignment, and Progress
  11. Medical Student Academic Support, Career Advising, and Educational Records
  12. Medical Student Health Services, Personal Counseling, and Financial Aid Services

Reaccreditation Timeline

The background image is A College of Medicine pillar is wrapped in a poster that reads College of Fostering Well-Rounded Students Medicine while two students talk in the background.

  • March 2023 to January 2024

    • Appoint steering committee members
    • Steering committee meeting to review the process
    • Distribute the DCI database to education faculty/staff
    • Database parts are returned and merged together
    • Finalize review of database
    • Appoint subcommittee members and chairs
    • Book weekly subcommittee meetings (dates/times/rooms)
    • Meet with each subcommittee to review tasks and disseminate database

    Begin…

    • Weekly meetings of LCME core group
    • Biweekly subcommittee meetings
    • Biweekly reports/meetings with chairs to review subcommittee progress

  • January 2024 to April 2024

    • Weekly meetings of LCME core group
    • Biweekly subcommittee meetings
    • Biweekly reports/meetings with chairs to review subcommittee progress
    • Steering committee meetings
    • Faculty Org and Student Leader meetings
    • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

  • May 2024 to August 2024

    • Weekly meetings of LCME core group
    • Biweekly subcommittee meetings
    • Biweekly reports/meetings with chairs to review subcommittee progress
    • Steering committee meetings
    • Faculty Org and Student Leader meetings
    • Final draft of subcommittee reports to steering committee
    • Steering committee draft, revision and finalization of Executive Summary
    • Consultants provide feedback on DCI and Executive Summary
    • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

  • September 2024 to December 2024

    • Weekly meetings of LCME core group
    • Steering committee meetings
    • Faculty Org and Student Leader meetings
    • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

  • January 2025 to March 2025

    • Weekly meetings of LCME core group
    • Steering committee meetings
    • Faculty Org and Student Leader meetings
    • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

  • April 2025 to June 2025

    • Weekly meetings of LCME core group
    • Steering committee meetings
    • Faculty Org and Student Leader meetings
    • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

  • 3 months before site visit

    • Weekly meetings of LCME core group
    • Steering committee meetings
    • Faculty Org and Student Leader meetings
    • Submit DCI and Executive Summary to LCME
    • Meet with action plan teams to implement changes
    • Identify PSCOM team for each site visit session
    • Meet with PSCOM site visit participants for first prep
    • Steering committee meetings
    • Faculty Org, Student Leader and Town Hall Meetings
    • Mock site visit

  • 2 months before site visit

    • Meet with action plan teams to implement changes
    • Steering committee meetings
    • Faculty Org, Student Leader and Town Hall Meetings
    • Debrief regarding mock visit and second prep with all faculty and students designated to meet with LCME site visit team

  • 1 month before site visit

    • Meet with action plan teams to implement changes
    • Steering committee meetings
    • Faculty Org, Student Leader and Town Hall Meetings
    • Debrief regarding mock visit and second prep with all faculty and students designated to meet with LCME site visit team
    • Update and submit any revisions for final DCI and Executive Summary

  • Site visit: 2025-26

    • Meet with action plan teams to implement changes
    • Debrief regarding mock visit and second prep with all faculty and students designated to meet with LCME site visit team
    • Finalize PSCOM site team session participants
    • Site Visit
    • Debrief LCME visit and identify issues that need to be addressed in the next year and with CQI committee

March 2023 to January 2024

  • Appoint steering committee members
  • Steering committee meeting to review the process
  • Distribute the DCI database to education faculty/staff
  • Database parts are returned and merged together
  • Finalize review of database
  • Appoint subcommittee members and chairs
  • Book weekly subcommittee meetings (dates/times/rooms)
  • Meet with each subcommittee to review tasks and disseminate database

Begin…

  • Weekly meetings of LCME core group
  • Biweekly subcommittee meetings
  • Biweekly reports/meetings with chairs to review subcommittee progress

January 2024 to April 2024

  • Weekly meetings of LCME core group
  • Biweekly subcommittee meetings
  • Biweekly reports/meetings with chairs to review subcommittee progress
  • Steering committee meetings
  • Faculty Org and Student Leader meetings
  • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

May 2024 to August 2024

  • Weekly meetings of LCME core group
  • Biweekly subcommittee meetings
  • Biweekly reports/meetings with chairs to review subcommittee progress
  • Steering committee meetings
  • Faculty Org and Student Leader meetings
  • Final draft of subcommittee reports to steering committee
  • Steering committee draft, revision and finalization of Executive Summary
  • Consultants provide feedback on DCI and Executive Summary
  • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

September 2024 to December 2024

  • Weekly meetings of LCME core group
  • Steering committee meetings
  • Faculty Org and Student Leader meetings
  • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

January 2025 to March 2025

  • Weekly meetings of LCME core group
  • Steering committee meetings
  • Faculty Org and Student Leader meetings
  • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

April 2025 to June 2025

  • Weekly meetings of LCME core group
  • Steering committee meetings
  • Faculty Org and Student Leader meetings
  • Based on DCI and subcommittee reports-Identify issues, collect relevant detailed data and create teams to address action plans for problematic elements

3 months before site visit

  • Weekly meetings of LCME core group
  • Steering committee meetings
  • Faculty Org and Student Leader meetings
  • Submit DCI and Executive Summary to LCME
  • Meet with action plan teams to implement changes
  • Identify PSCOM team for each site visit session
  • Meet with PSCOM site visit participants for first prep
  • Steering committee meetings
  • Faculty Org, Student Leader and Town Hall Meetings
  • Mock site visit

2 months before site visit

  • Meet with action plan teams to implement changes
  • Steering committee meetings
  • Faculty Org, Student Leader and Town Hall Meetings
  • Debrief regarding mock visit and second prep with all faculty and students designated to meet with LCME site visit team

1 month before site visit

  • Meet with action plan teams to implement changes
  • Steering committee meetings
  • Faculty Org, Student Leader and Town Hall Meetings
  • Debrief regarding mock visit and second prep with all faculty and students designated to meet with LCME site visit team
  • Update and submit any revisions for final DCI and Executive Summary

Site visit: 2025-26

  • Meet with action plan teams to implement changes
  • Debrief regarding mock visit and second prep with all faculty and students designated to meet with LCME site visit team
  • Finalize PSCOM site team session participants
  • Site Visit
  • Debrief LCME visit and identify issues that need to be addressed in the next year and with CQI committee

Conducting a Self-Study

  • Self-study process

    • Collect and review data about the medical school and its educational programs
    • Identify institutional strengths and issues requiring actions
    • Define strategies to ensure that the strengths are maintained and any problems are addressed effectively

  • Self-study structure

    Steering Committee
    Medical Student Self-Study Committee (ISA)
    5 self-study committees
    Institutional Setting
    Faculty
    Medical Education
    Education Resources
    Student Services

    • Review relevant data from DCI (data collection instrument)
    • Assess compliance with standards relevant to their committee
    • Write a summary report:
      • conclusions about programmatic strengths and challenges, areas of partial or substantial noncompliance with accreditation standards
      • recommendations for actions to alleviate any identified problems
    • Each committee’s summary is incorporated by the LCME leads into an executive summary

  • Institution: organizational planning and operations; leadership and administration

    Faculty: productivity, participation, preparation and policies

    Educational Resources: finances, buildings and equipment, library, information technology and student safety and security

    Medical Education: curriculum, student supervision and assessment, student and patient safety and preparation and oversight of instructors

    Student Services: admissions, academic and career advising, financial aid, debt management, student wellbeing

  • Committee overview

    • Approve the LCME self-study timeline, committee chairs and members
    • Oversight of the LCME self-study process
    • Meet quarterly to review the progress of the self-study
    • Provide feedback about the self-study reports and executive summary

    Committee members

    • Chair: Erica Friedman, Vice Dean for Educational Affairs
    • Britta Thompson, Associate Dean for Evaluation and Assessment
    • Eileen Moser, Associate Dean for Medical Education
    • Manny Williams, Associate Dean for Student Affairs
    • Bernadette Gilbert, Associate Dean for Admissions and Student Aid
    • Leslie Parent, Vice Dean for Graduate Affairs
    • Tomi Dreibelbis, Senior Director of Educational Affairs
    • Robin Anderson, Director of CQI, Office of Evaluation and Assessment
    • Susan Glod, Director of Woodward Center for Faculty Development
    • Susan Promes, Chair of Emergency Medicine
    • Amyn Rojiani, Chair of Pathology
    • Ted Bollard, Associate Dean for Graduate Medical Education
    • Inginia Genoa, Vice Dean for Diversity, Equity and Belonging
    • Jennifer Feeman, Assistant Vice President for Finance and Business
    • George Blackall, Interim Vice Dean for Faculty Affairs
    • Mark Stephens, Associate Dean for Medical Education, UPC track
    • Larissa Whitney, Director of Physician Assistant Program
    • James Broach, Chair of Biochemistry & Molecular Biology
    • Sue Grigson-Kennedy, Chair of Neural and Behavioral Sciences
    • Penn State Health System representative – Deborah Addo
    • 2 MD students- TBD; 1 MD/PhD student- TBD; 1 Resident- TBD

Self-study process

  • Collect and review data about the medical school and its educational programs
  • Identify institutional strengths and issues requiring actions
  • Define strategies to ensure that the strengths are maintained and any problems are addressed effectively

Self-study structure

Steering Committee
Medical Student Self-Study Committee (ISA)
5 self-study committees
Institutional Setting
Faculty
Medical Education
Education Resources
Student Services
  • Review relevant data from DCI (data collection instrument)
  • Assess compliance with standards relevant to their committee
  • Write a summary report:
    • conclusions about programmatic strengths and challenges, areas of partial or substantial noncompliance with accreditation standards
    • recommendations for actions to alleviate any identified problems
  • Each committee’s summary is incorporated by the LCME leads into an executive summary

Institution: organizational planning and operations; leadership and administration

Faculty: productivity, participation, preparation and policies

Educational Resources: finances, buildings and equipment, library, information technology and student safety and security

Medical Education: curriculum, student supervision and assessment, student and patient safety and preparation and oversight of instructors

Student Services: admissions, academic and career advising, financial aid, debt management, student wellbeing

Committee overview

  • Approve the LCME self-study timeline, committee chairs and members
  • Oversight of the LCME self-study process
  • Meet quarterly to review the progress of the self-study
  • Provide feedback about the self-study reports and executive summary

Committee members

  • Chair: Erica Friedman, Vice Dean for Educational Affairs
  • Britta Thompson, Associate Dean for Evaluation and Assessment
  • Eileen Moser, Associate Dean for Medical Education
  • Manny Williams, Associate Dean for Student Affairs
  • Bernadette Gilbert, Associate Dean for Admissions and Student Aid
  • Leslie Parent, Vice Dean for Graduate Affairs
  • Tomi Dreibelbis, Senior Director of Educational Affairs
  • Robin Anderson, Director of CQI, Office of Evaluation and Assessment
  • Susan Glod, Director of Woodward Center for Faculty Development
  • Susan Promes, Chair of Emergency Medicine
  • Amyn Rojiani, Chair of Pathology
  • Ted Bollard, Associate Dean for Graduate Medical Education
  • Inginia Genoa, Vice Dean for Diversity, Equity and Belonging
  • Jennifer Feeman, Assistant Vice President for Finance and Business
  • George Blackall, Interim Vice Dean for Faculty Affairs
  • Mark Stephens, Associate Dean for Medical Education, UPC track
  • Larissa Whitney, Director of Physician Assistant Program
  • James Broach, Chair of Biochemistry & Molecular Biology
  • Sue Grigson-Kennedy, Chair of Neural and Behavioral Sciences
  • Penn State Health System representative – Deborah Addo
  • 2 MD students- TBD; 1 MD/PhD student- TBD; 1 Resident- TBD