Job Description

POSITION SUMMARY :

Under the guidance of Administrative Director for Accreditation/Strategy, the Accreditation Manager leads efforts to ensure organizational compliance with appropriate regulatory accreditation standards as required by the ACGME and other regulatory authorities of Graduate Medical Education programs. They provide monitoring, oversight, and support for 13 accredited residency/fellowship programs, in addition to a portfolio of non-accredited programs, that together include ~200 resident and fellows at Boston Medical Center - Brighton. Drawing on a broad understanding of graduate medical education practices and policies, and displaying a high degree of initiative and independent judgment, the Accreditation Manager will proactively plan, implement, coordinate and continually improve Boston Medical Center Health System (BMCHS) efforts related to GME accreditation. Partnering with Program Clinical leaders they will collaborate develop tools/systems/processes to ensure our programs and institution address all requirements of governing bodies. This position functions as a liaison between the BMCHS GME Office and the residency/fellowship training programs at BMC - Brighton and affiliated hospitals, health centers, and community training sites, as well as other internal departments within BMC - Brighton.

Position: Accreditation Manager Graduate Medical Education

Department: Medical Staff Affairs

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Office of GME Responsibilities.

• Establish and maintain effective working relationship between GME Office and physician training programs (i.e. residencies and fellowships).
• Maintain current knowledge of Joint Commission, Accreditation Council for Graduate Medical Education (ACGME), Residency Review Committee, National Residency Matching Program, Educational Commission for Foreign Medical Graduates, Council on Podiatric Medical Education policies, procedures, and requirements.
• Serve as expert for Program Directors and Program Administrators on GME policies and procedures. Work to decrease variation among training programs across multiple processes, including evaluations, elective tracking, and Annual Program Evaluation.
• Review and oversee communications between programs and accrediting bodies, such as ACGME, including annual ADS updates and responses to citations.
• Counsel residents and fellows on internal and external GME policies and procedures.
• Participate in professional development activities through involvement in professional organizations and by attending conferences.
• Partner with other members of GME team to address accreditation requirements and facilitate the continued growth and improvement of the clinical learning environment.

Graduate Medical Education Committee (GMEC) and GMEC Subcommittees Responsibilities

• Oversee administrative staff support to the GMEC & Subcommittees including:
• Ensure that GMEC meeting agendas and minutes address all accreditation requirements.
• Maintain list of GMEC & Subcommittee follow-up actions and ensure completion.
• Ensure that GMEC meetings have all required participants
• Manage communications regarding GMEC decisions, recommendations & actions.
• Responsible for all policies and necessary approvals funneled through GMEC, so as to meet all ACGME requirements.
• Review and provide assessment on all Non-Standard Training Program applications prior to submission GMEC or any applicable sub-committees. Ensure that all requirements established by the GMEC are met (e.g., description of the program, goals and objectives, methods of evaluation, funding source, duration of program).
• Develop and make presentations at GMEC and Subcommittees as appropriate.

Accreditation Responsibilities 

• Continuously update and maintain accreditation data – applications received and submitted, upcoming site visit data (dates, accreditation field staff, debriefing afterwards) and accreditation results for all accreditation decisions.
• Maintain institutional information in ACGME database WebADS. Served as an expert on accreditation requirements for both institution and programs.
• Review programs submissions in ADS including Annual ADS Updates
• Identify need for, draft, edit, and revise GME institutional, program, and trainee policies in compliance with ACGME requirements and the CIR (resident union) contract.
• Maintain a broad and current knowledge and understanding of ACGME policies and procedures including the appeals process
• Lead the preparation for ACGME Institutional and Program Site Visits, including CLER visits. Ensures that the institution and programs are in a “constant state of readiness”.
• Manage the APE (Annual Program Evaluation) for all ACGME Programs.
• Manage the ACGME programs Winter Check ins and Spring Responses.
• Other ongoing ACGME accreditation activities including proofreading and editing of all applications/renewal of accreditation documents for content, grammar and compliance with regulations
• Preparing residents/fellows, faculty, and Program Director for likely questions on accreditation site visits and ensuring that all programs, trainees, and staff are appropriately prepared for these activities.
• Oversee program maintenance of accreditation for all accrediting bodies, including ACGME, CPME, and others as appropriate.
• Provide expertise and consultation to Programs in their preparation for the Annual Program Evaluation & continuous data collection, including but not limited to, ADS annual update, Resident and Faculty Surveys, Milestone data, and ACGME Complaints.

JOB REQUIREMENTS

REQUIRED EDUCATION AND EXPERIENCE:

BA/BS degree in Business Administration or related field required (or equivalent relevant experience in lieu of education).

At least 5 years of related work experience required.

PREFERRED EDUCATION AND EXPERIENCE (If none, please enter “N/A”):

Experience in the area of GME management strongly preferred

KNOWLEDGE, SKILLS & ABILITIES (KSAs) (If none, please enter “N/A”):

• Must demonstrate ability to manage complex administrative activities and be flexible to adapt to unexpected changes in requirements. 
• Exceptional organizational skills, analytical skills, ability to work independently and under pressure with minimal supervision, ability to prioritize and manage simultaneous needs of the department.
• Strong interpersonal skills and experience navigating complex organizations
• Prefer strong knowledge of Graduate Medical Education and the Accreditation Council for Graduate Medical Education
• Strong verbal and written communication skills
• Ability to build relationships and influence with key stakeholders to provide effective support and guidance of physician Program Directors, Residents/Fellows, GME Staff, and others.
• Must be exceptionally organized to prioritize a multitude of diverse activities so as to meet strict deadlines
• Dedicated team player with the willingness and desire to learn and grow within the organization
• Professional in conduct and appearance
• Proficient with standard software used in healthcare settings (i.e. MS Office products) and ability to learn new software (i.e. New Innovations)

Equal Opportunity Employer/Disabled/Veterans

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