Institutional Accreditation Manager

Essential Job Statements

Accreditation and Compliance (Institutional and Program)

Ensure that the institution and its graduate medical education (GME) training programs meets or exceeds requirements articulated by accrediting bodies (e.g. ACGME, CODA) by collaborating with and supporting the DIO, Associate DIO, Graduate Medical Education Committee, and individual program leaders.

Provide training and serve as a liaison between program directors, program coordinators, and GME Office to achieve accreditation excellence in graduate medical education.

Track data submission and reporting schedules for all medical and dental programs to ensure compliance with all accreditation requirements for the ACGME, Commission on Dental Accreditation (CODA) and Specialty boards.

Counsel program directors and program coordinators in preparation of: New Program Applications, Participating Site modification, AAMC Fellowship and Residency Electronic Interactive Database (FREIDA) and GME Track, New Innovations Annual Program Evaluations, ACGME Resident & Faculty Surveys, Citation Responses and Action plans, Self-Studies and management of special reviews as required.

Create and maintain performance dashboard of all ACGME and non-ACGME programs.

Develop and update GME templates using internal best practices and/or national outstanding models (benchmark practices) to assist the institution and the GME programs in meeting and exceeding compliance with accreditation body standards.

Compile and monitor institutional and program citations, areas for improvement, progress reports and plans.

Monitor and facilitate DIO approval of new program applications, program director changes, temporary and permanent complement increases, and programs' participating sites additions and deletion.

In collaboration with DIO/Assoc. DIO, compile data for the institutional "scorecard" - data may include accreditation information, quality data points, and demographic information.

Plan logistics and develop professional development series for program coordinators.

Collaborate with Program Directors, teaching faculty, and program coordinators to identify professional development needs related o accreditation and education.

Assist in creating and compiling program data for the Annual Institutional Review (AIR) with the DIO, Associate DIO, and GMEC

Work in close coordination with the DIO, Associate DIO, GMEC, and GME Operations Manager to accomplish the aforementioned activities.

In concert with the GMEC Professional Development Committee and the GME Education Coordinator, develop and deliver professional development education for program directors and program coordinators

Graduate Medical Education Committee

In coordination with the GME Leadership team, set the agenda, manage the monthly GMEC logistics, meeting minutes, and track the results of the initiatives ensuring that the GMEC meets its responsibilities, pursuant to ACGME institutional requirements and institutional policies and procedures.

Distributes the GMEC agenda and supporting materials to GMEC members at least 5 business days prior to the meeting.

Maintain accurate and detailed meeting minutes with annotations referencing specific ACGME institutional requirements.

Ensure follow through of GMEC Action Items

Maintain database of program level changes (linked to GMEC minutes) for program director and complement changes as well as new programs (including funding approvals)

GMEC Oversight Subcommittee

Provide support for the GMEC Oversight Subcommittee which includes creating the agenda in coordination with the committee Chair and DIO and maintaining meeting minutes.

Compile, analyze, and summarize data (e.g. Annual Program Evaluation reviews, duty hour reporting) for the Oversight committee and GMEC.

Compile and disseminate meeting agenda and supporting materials.

Ensure all action plans related to clinical work hours are addressed to eliminate risk of further violations.

Ensure follow through of action items

Clinical Learning Environment (C.L.E.) Subcommittee

Provide support for the GMEC CLER Subcommittee which includes creating the agenda and maintain effective minutes, in coordination with the committee Chair and Associate DIO

Coordinate with sponsoring institution officials to reconcile CLER items.

Coordinate CLER site visit, pre-meetings, and debriefs.

Collaborate with Associate DIO and the Patient Safety and Quality director to obtain reports to identify areas of improvement and trends

Institutional Affiliation Agreements and Program Letters of Agreement (PLA)

Counsel programs on ACGME required PLAs between programs and participating sites.

Review and ensure PLAs meet ACGME requirements and institutional policies and procedures.

Track Affiliation Agreements and PLAs in New Innovations

Ensure that Affiliation Agreements and PLAs are complete and up to date. Monitor agreement expiration dates and proactively work with programs to renew agreements starting at 90 days prior to the expiration dates.

Work in close coordination with Operations Manager regarding new Affiliation Agreements and PLAs.

Ensure that the ACGME Accreditation Data System (ADS) participating site list is up to date and accurate

ACGME documentation, Accreditation Data System (ADS), milestones, surveys, and annual program evaluations

Oversee ACGME ADS system for the Institution and provides technical assistance to programs completing program and resident submissions and updates pursuant to ACGME requirements.

Maintain records of all ACGME and CODA accreditation communications and actions.

Update Web ADS with program director and program coordinator changes

Oversee programs information updates in ACGME ADS to ensure program compliance with annual ADS updates, ACGME resident faculty surveys, milestone reporting, and Annual Program Evaluations (APEs) by required deadlines.

Internal Focused and Special Reviews

Assist with the administration of all special program reviews.

Manages the schedule of all reviews and ensures timely communications to programs being reviewed and review team members.

Compile special review documentation and facilitate dissemination to review team members.

Attend special review meetings and document minutes.

Monitor corrective actions and any required review report follow-up, pursuant to GMEC direction.

ACGME, CODA (and other accrediting body) site visits and self-studies

Serve as a support and resource to program directors and program coordinators in their preparation for accrediting body site visits.

Plan logistics and schedule all participants for mock site visits.

USMLE and COMLEX Step 3 Examination

Ensure compliance with GMEC policy of USMLE and COMLEX step 3 examinations through communications with program directors and program coordinators. This includes running reports of non-compliant house staff and appropriate follow through.

Stay abreast of changes with USMLE and COMLEX examinations.

Work in close coordination with Operations Manager and Resources Coordinator regarding non-compliant house staff.

Additional Responsibilities/Credentialing

Assist with the institutional onboarding and orientation of new house staff.

Assist in the offboarding of house staff transitioning from GME.

Work with Administrative Coordinator to facilitate the completion and collection of accurate initial credentialing documentation and final training verification from graduating/departing residents.

Monitor clinical and educational work hours in the Residency Management System

Collaborate with Operations Manager and Program Coordinator advisory group to ensure appropriate training for program coordinators in New Innovations is utilized to create rotation evaluations that map to the milestones and curriculum goals and objectives are attached to each rotation.

Work with the Education coordinator to identify training programs core curriculum and patient safety and quality curriculum in needed content areas and resources.

Develop system for monitoring quality metrics.

Track all disciplinary actions.

Perform other duties as assigned.

Accepts alternate assignments, as required, graciously.

Patient Population

Not applicable to this position.

Employment Qualifications

Required Education:

Bachelor's degree in a related field required.

A combination of education and experience may be considered in lieu of a degree.

Preferred Education:

Master's Degree

Licensure/Certification Required:

Licensure/Certification Preferred:

Training Administrators of Graduate Medical Education (TAGME)

Minimum Qualifications

Years and Type of Required Experience

Five (5) years of work experience in healthcare, education, or accreditation organization in a coordination or management role responsible for system and process development

Other Knowledge, Skills and Abilities Required:

Current knowledge of ACGME and specialty board requirements and the ability to apply requirements to GME training programs.

Proficiency with Microsoft Office and Office 365 applications, including Word, Excel, and PowerPoint, and Teams.

Effective written and verbal communication skills.

Established record of facilitation and working in multidisciplinary teams and of collaborating with a wide variety of stakeholders

Ability to organize information.

Ability to handle sensitive information with absolute confidentiality.

Ability to make decisions independently or to escalate issues as needed.

Ability to manage and prioritize competing workflows.

Close attention to detail

Cultural Responsiveness

Other Knowledge, Skills and Abilities Preferred:

Experience with New Innovations Residency Management System, ACGME ADS, and AAMC GME Track.

Working Conditions

Periods of high stress and fluctuating workloads may occur.
May have periods of constant interruptions.

Prolonged periods of working alone.

Physical Requirements

Physical Demands: Lifting/ Carrying (0-50 lbs.), Push/ Pull (0-50 lbs.), Stoop, Kneel, Squat, Bending

Work Position: Sitting, Walking, Standing

Additional Physical Requirements/ Hazards

Physical Requirements: Manual dexterity (eye/hand coordination), Hear alarms/telephone/tape recorder,

Hazards:

Mental/Sensory -Emotional

Mental / Sensory: Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking

Emotional: Fast pace environment, Able to Handle Multiple Priorities, Frequent and Intense Customer Interactions, Able to Adapt to Frequent Change

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.