The Accreditation Administrator supports the work of multiple (typically two-to-four) Review Committees in their review and accreditation of graduate medical education (GME) programs. The Accreditation Administrator is responsible for coordinating Review Committee activities; managing the materials and records needed to review and track accreditation; performing follow-up on Review Committee decisions; and providing instruction/serving as a resource to GME program staff members and residents/fellows on accreditation requirements and issues. Successful performance of the job duties requires comprehension of accreditation policies and procedures, and the ability to recognize precedents.
Job Context/Background Information
The Review Committees are composed of volunteer physicians who review GME programs for accreditation purposes. The Review Committees review extensive information provided by the programs, site visit reports prepared by ACGME site visitors, and other materials relevant to each review. Based on their reviews, the Review Committees issue findings that require varying levels of follow-up by ACGME staff members.
Each Review Committee typically meets two-to-three times per year to evaluate the programs scheduled for review, and may have one additional administrative meeting. Between meetings, requests for program changes (e.g., changes in the number of residents, or changes in program director) and correspondence to and from programs with issues are processed by the ACGME Review Committee staff. In addition, Review Committees periodically develop or review and revise Program Requirements and related documents, such as FAQs.
Designated institutional officials (DIOs), program directors, program faculty members, and program coordinators regularly contact the ACGME with questions or concerns. Residents and fellows also occasionally contact the ACGME. These interactions are generally straightforward, but occasionally require more in-depth knowledge of the accreditation requirements and processes. The ACGME Review Committee staff conducts periodic training sessions for program staff members on these topics.
Primary Duties and Responsibilities
The primary duties and responsibilities of this position include:
Review Committee Meeting Preparation
Every program in a designated specialty (e.g., internal medicine and its subspecialties) will be reviewed during a multi-day Review Committee meeting on an annual basis. During this and additional meetings throughout the year, programs will have other reviews as needed (e.g., to go over the outcomes of progress reports, Self-Study Visits, focused site visits, etc.). The Accreditation Administrator oversees and assists in preparation for all of these reviews, and this includes:
· Providing program personnel with deadlines for submitting materials for upcoming Review Committee meetings;
· Preparing program review agendas, including both status (i.e., accreditation decisions) and non-status items (e.g., progress reports, complement increase requests, complaints, etc.); inventorying and evaluating program files, identifying review purpose, and determining the documentation required for the specific review; and ensuring the meeting agenda includes all required programs and types of reviews needed for each program;
· Working up program materials for the reviewers and the Review Committee meeting; assigning Committee members to review each program scheduled for review; ensuring there are no conflicts of interest for reviewers, and that workload is appropriately distributed among reviewers, which may require matching reviewers to assignments in terms of skill set and knowledge;
· Creating and editing GroveSite (an electronic information sharing site) pages with reviewer work-ups and resource materials, Review Committee membership information, and other Review Committee business information or data; managing Review Committee member administration on GroveSite and/or in the ACGME Accreditation Data System (ADS) (e.g., enrollment, security settings, etc.); and file maintenance;
· Overseeing the preparation of the agenda books for Review Committee members to use during their meetings;
· Communicating with, and, when appropriate, educating Review Committee members to ensure accurate completion of all documentation for meetings, to include taking responsibility for responding to inquiries, troubleshooting issues related to access to information, and identifying missing information/documentation; and,
· Managing meeting logistics for Review Committee meetings using existing hotel contracts; and facilitating arrangement of hotel accommodations, to include planning and arranging meeting room set-up, making meal arrangements, and managing on-site logistics.
Review Committee Meetings
The Accreditation Administrator staffs several Review Committee meetings each year, for which responsibilities include:
· Taking notes for meeting minutes; understanding program accreditation discussions; and summarizing complex discussions into salient points;
· Providing additional program information to Review Committee members if requested;
· Participating in the scheduling of future Review Committee meeting dates;
· Participating in the discussion of travel/financial policies, collection of conflict of interest agreements, and performance of other work as needed; and,
· Representing the ACGME’s mission and values, and adhering to organizational policies and procedures as appropriate in Review Committee meetings.
The Accreditation Administrator assists the Executive Director in documenting and following through on Review Committee decisions and business, and communicating review results to programs. The Administrator has primary responsibility for facilitating and tracking everything that needs to be done post-meeting, including:
· Drafting meeting minutes for review by the Executive Director; and entering Review Committee decisions and actions into ADS, to include the status outcomes of reviews and requests and the Review Committee’s decisions (ADS generates an automatic e-mail notifying programs of accreditation decisions);
· Notifying the Director, ACGME Governance, Appeals, Policies, and Procedures of any adverse action(s) within 10 days of each Review Committee meeting;
· Working with the Executive Director to prepare Letters of Notification (LoNs) to the programs that detail Program Requirement non-compliance (citations) and the Review Committee review results; and drafting assigned LoNs by summarizing Review Committee decisions and required actions (most letters are straightforward, but some require research if reviewers’ citations or examples are unclear);
· Running drafts and posting final completed LoNs to ADS (ADS automatically notifies programs of the availability of the letters); and,
· Performing, and/or overseeing the Accreditation Assistant in the processing of meeting and Review Committee member expense reports, and providing assistance to Review Committee members with questions on accessing the ACGME Reimbursement System; and personally reviewing and approving (signing off on) hotel bills and member meeting expenses for all Review Committee meetings.
Interim Program Correspondence and Requests
The Accreditation Administrator monitors interim correspondence from programs and ensures appropriate follow-up, which includes:
· Monitoring, or overseeing the monitoring of interim requests made by programs in ADS, and ensuring appropriate processing of requests (interim requests are generally routine and involve issues such as changes in the number of residents or fellows in the program, in the program director, and in participating sites); and,
· Monitoring interim correspondence with programs and ensuring appropriate handling of this correspondence.
Resource to Program Staff
The Accreditation Administrator serves as a resource to program staff, including program directors and coordinators, providing information about preparation for review and about the Program Requirements. The highest volume of communication from the programs is related to preparation for site visits and clarification of citations after the LoNs are received. The Accreditation Administrator’s duties include:
· Responding to inquiries from external constituents, such as program staff members, and answering questions about procedures, completing forms, and annual data updates;
· Preparing for, attending, presenting at, and staffing ACGME national meetings and workshops, including the Annual Educational Conference, New Member Orientation, and Coordinators Workshops; and,
· Developing new or using existing presentations to speak to national specialty groups or program coordinator groups.
Accreditation Team Responsibilities
The Accreditation Administrator performs a number of activities to organize and manage the workflow of the Review Committee staff, and to support and improve the overall operations of the DAS, including:
· Providing task management and training to Accreditation Assistants, as appropriate; and overseeing and assessing projects given to the Assistant(s) by other team members;
· Serving on advisory teams within the DAS for the purpose of improving DAS processes and services;
· Providing training for DAS employees on processes and procedures;
· Monitoring and processing new applications;
· Providing support to sub-committees, as needed; and,
· Assisting in the preparation of reports for the Monitoring Committee and other ACGME Board of Directors committees, as necessary.
Records and Information Resources
The Accreditation Administrator is responsible for maintaining records and posted information for his or her assigned Review Committees, including:
· Maintaining specialty-specific GroveSite pages; routinely updating Review Committee web pages on the ACGME website;
· Coordinating Review Committee membership activities; maintaining current Review Committee member rosters; and advising Review Committee members on ACGME policies and procedures as they apply to their Review Committee activities and responsibilities;
· Supporting the Review Committees in the activities relating to the updating and revising of Program Requirements by electronically formatting and recording their changes;
· Assuming accountability for the maintenance and accuracy of data in all permanent files and computer documents for the programs over which the assigned Review Committees have oversight;
· Maintaining FAQs and Citation Glossaries for the Review Committees’ specialties and related subspecialties; and,
· Performing additional duties as assigned.
Education, Knowledge, Skills, and Abilities
· Bachelor’s degree or equivalent skills and experience strongly preferred for Accreditation Administrator position.
· Previous experience in the medical education field, a medical society, hospital administration, or a similar setting desirable.
· Strong interpersonal, verbal, and written communication skills, with a demonstrated ability to communicate with a variety of people, and the ability to write clear communications that convey complex information required.
· Demonstrated customer-oriented approach to both internal and external communication required.
· Superior administrative, organizational, and workflow management skills, as well as proven project management skills required.
· Availability for significant travel and scheduling flexibility required.
· Strong attention to detail, accuracy, and follow-up required.
· Must be deadline-oriented, skilled in working under tight timelines, and comfortable balancing multiple projects and priorities simultaneously using a flexible approach.
· Demonstrated ability to work independently with minimal supervision required.
· Demonstrated good judgment, common sense, and dependability required.
· Proficiency in Microsoft Word, Excel, Outlook, PowerPoint, and Adobe Acrobat Pro required.
· Keyboarding skills of at least 45 wpm required.
· Strong editing skills required.
· Ability to anticipate and troubleshoot problems required.
· Demonstrated competence in the knowledge of basic statistical concepts, such as descriptive statistics required.
· Ability to analyze, interpret, and report data (quantitative: numerical and graphical; and qualitative) for outliers, trends, and/or themes according to previously determined criteria required.
· Previous experience with GroveSite, or online class courses via platforms such as BlackBoard, WebCT, Moogle desirable.
· Enthusiastic team player with a strong work ethic and demonstrated flexibility preferred.
The ACGME accredits Sponsoring Institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of import in graduate medical education. The ACGME employs best practices, research, and advancements across the continuum of medical education to demonstrate its dedication to enhancing health care and graduate medical education. The ACGME is committed to improving the patient care delivered by resident and fellow physicians today, and in their future independent practice, and to doing so in clinical learning environments characterized by excellence in care, safety, and professionalism.