Boston Medical Center Manager of Graduate Medical Education Accreditation, Medical Staff Affair (40 hrs, Days) in Boston, Massachusetts

Manager of Graduate Medical Education Accreditation, Medical Staff Affair (40 hrs, Days)

Boston, MA


Job ID 5238307 Date posted 07/28/2017

Boston Medical Center (BMC) is more than a hospital. It´s a network of support and care that touches the lives of hundreds of thousands of people in need each year. It is the largest and busiest provider of trauma and emergency services in New England. Emphasizing community-based care, BMC is committed to providing consistently excellent and accessible health services to all—and is the largest safety-net hospital in New England. The hospital is also the primary teaching affiliate of the nationally ranked Boston University School of Medicine (BUSM) and a founding partner of Boston HealthNet – an integrated health care delivery systems that includes many community health centers. BMC provides a full range of pediatric and adult care services, from primary to family medicine to advanced specialty care.

BMC is also committed to our employees, who are a very important piece to who we are. We pride ourselves in providing equal employment opportunity and non-discrimination for all employees and qualified applicants without regard to a person's race, color, gender, age, religion, national origin, ancestry, disability, veteran status, genetic information, sexual orientation or any characteristic protected under applicable law. BMC will make reasonable accommodations for qualified individuals with known disabilities, in accordance with applicable law.

Under the general supervision of the Administrative Director of Graduate Medical Education (GME), the Manager of GME Accreditation is responsible for regulatory accreditation and compliance functions of the Boston Medical Center Office of Graduate Medical Education, which provides monitoring, oversight, and support for over forty (40) accredited residency/fellowship programs and over thirty (20) nonstandard fellowship programs with more than 600 residents and fellows based at Boston Medical Center. 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 continually assess and direct a wide range of accreditation activities, including compliance monitoring, long-range strategic planning and other projects as needed. This position functions as a liaison between the Office of GME and the residency programs at BMC and affiliated hospitals, health centers, and community training sites as well as internal departments within Boston Medical Center.

  1. Office of GME Responsibilities.
  • 1.1. Establish and maintain effective working relationship between GME Office and physician training programs (>40) as well as non-standard training programs (>20).

  • 1.2. Maintain current knowledge of Joint Commission on Accreditation of Healthcare Organizations, Accreditation Council for Graduate Medical Education, Residency Review Committee, National Residency Matching Program, Educational Commission for Foreign Medical Graduates, Council on Podiatric Medical Education and Board of Registration in Medicine requirements.

  • 1.3. Educate MD Program Directors, Program Managers/Coordinators on GME policies and procedures. Work to decrease variation among training programs across multiple processes, including evaluations, elective tracking, and Annual Program Evaluation.

  • 1.4. Counsel residents and fellows on internal and external GME policies and procedures.

  • 1.5. Complete surveys relating to GME (e.g., American Medical Association, Association of American Medical College, Accreditation Council for Graduate Medical Education, Liaison Committee for Medical Education, and Veterans Administration Annual Survey).

  • 1.6. In collaboration with Systems Manager, produce and maintain resources and links available on the BMC GME website.

  • 1.7 In partnership with the DIO, plan, organize, and produce the institutional orientation program for all new residents and fellows, including developing the curriculum based on a needs assessment and balancing content with budget requirements. This includes the application of adult learning theory, instructional design, and incorporation of clinical simulation into the orientation program. Administrative activities includes booking speakers, rooms, catering. Attend orientation.

  • 1.8 Review, program, away elective and rotator affiliation agreements (200 agreements) for hospital purposes.

  • 1.9 Participate in professional development activities through involvement in professional organizations and by attending conferences.

  1. Graduate Medical Education Committee (GMEC) and GMEC Subcommittees Responsibilities
  • 2.1. Oversee administrative staff support to the GMEC & Subcommittees including:

  • 2.1.1. Schedule all GMEC and Subcommittee meetings.

  • 2.1.2. Make recommendations, research and develop agenda items, coordinate presentations and materials and schedule speakers, prepare and distribute agenda packages.

  • 2.1.3. Take minutes, maintain attendance reports, give reports and maintain official records for accreditation purposes.

  • 2.1.4. Maintain list of GMEC & Subcommittee follow-up actions and ensure completion.

  • 2.2. Draft communications regarding GMEC decisions, recommendations & actions.

  • 2.3. Write and publish minutes and other documents (e.g. policies, guidelines) used/approved by the Committee.

  • 2.4. Review Non-Standard Training Program applications prior to submission to Residency Advisory Committee and GMEC. 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).

  • 2.5. Develop and make presentations at Graduate Medical Education Committee and Subcommittees.

  1. Accreditation Responsibilities

Institutional Level

  • 3.1. Manage all aspects and preparation for ACGME institutional accreditation (Clinical Learning Environment Review Program-CLER, Next Accreditation System - NAS or other process per ACGME).

  • 3.1.1. CLER Program includes assessment of the following domains: Patient Safety, Quality Improvement, Transitions in Care, Supervision, Duty Hours Oversight, Fatigue Management and Mitigation and Professionalism.

  • 3.1.2. CLER & Sponsoring Institution Site Visit Preparation

  • Pre-visit background materials

  • Scheduling of group meetings (Sr. Leadership, DIO, Quality and Patient Safety Leadership, Resident & Fellows, Faculty, MD Program Directors)

  • Coordination of Walking Rounds

  • Coordination of site visit logistics (room reservation, badges, meals, transportation)

  • 3.1.3. Faculty Development as related to CLER including needs assessment, curriculum design and delivery

  • 3.1.4. In collaboration with QI Analyst, create and maintain registry/database of pertinent metrics.

  • 3.1.5. Other ongoing ACGME accreditation activities include: proofreading and editing of all applications/renewal of accreditation documents for content, grammar and compliance with regulations

  • 3.1.6. Preparing residents/fellows, faculty, and MD Program Director for likely questions on regulatory site visits and coaching on site visit etiquette

  • 3.1.7. Serve as institutional expert on WebADS, the accreditation database utilized by 40+ programs. Answer basic questions and refer to WebADS staff as needed.

  • 3.1.8. Assist DIO in preparation of ACGME Institutional Review Document (IRD) that determines BMC’s designation as an accredited teaching hospital eligible for Medicare GME funds.

  • 3.2. Identify need for, draft, edit, and revise GME institutional, program and trainee policies in compliance with ACGME requirements and the CIR contract.

  • 3.3. Initiate, update, review and maintain master, agreements for residency and accreditation purposes. Develop and initiate new agreements as needed (when new sites are added to the programs).

  • 3.4. Maintain institutional information in ACGME database WebADS

  • 3.5. Have a broad knowledge and understanding of ACGME policies and procedures including the appeals process.

Program Level

  • 3.6. Oversee program accreditation for ACGME and other nationally accredited GME programs (e.g., CPME).

  • 3.7. Provide expertise and guidance to Programs in their preparation for the Annual Program Evaluation & continuous data collection, including the following:

  • ADS annual database update

  • ACGME Resident Survey

  • ADGME Faculty Survey

  • Milestone data

  • Certification examination performance

  • Case Log data

  • Hospital accreditation data

  • Faculty and resident scholarly activity and productivity

  • Other data (episodic)

  • ACGME Complaints (Section 23.10)

  • Verified public information

  • Historical accreditation decisions/citations

  • Institutional quality and safety metrics

  • 3.8. Manage ACGME web-based system that supports accreditation information.

  • 3.9. Assists in the development of residency/fellowship program educational goals and objectives. This includes 1:1 diagnostic sessions with MD Program Directors designing program curriculum such that content, teaching methodology and evaluation techniques are defined and articulated for each learning experience.

  • 3.10. Coordinate and participate in Special and Focused Reviews which include meeting with residents and faculty to insure institutional and program compliance with accreditation requirements and presenting findings at GMEC meetings. Prior to the review, develop program specific questions for the interview with the residents to assure compliance with program requirements. Prepare a written program profile after each review summarizing the program’s status relative to the program requirements. Circulate the profile amongst the affected residents and modify the report as necessary. Present the report to the Program Director and faculty for their input. Present report to the Residency Advisory Committee and the GMEC.

Must adhere to all of BMC’s RESPECT behavioral standards.

  • BA/BS degree in Business Administration or related field.

  • At least 5 years of related experience required; experience managing several direct reports required; experience in the area of GME management preferred.

  • Demonstrates, at all times, a professional demeanor and appearance.

  • Must demonstrate ability to supervise and manage complex administrative activities, flexible and energetic. Should have exceptional organizational skills, strong analytical skills, ability to work independently and under pressure with minimal supervision, ability to prioritize and manage simultaneous needs of the department.

  • Requires knowledge of all components of the medical education process, including undergraduate medical education, postgraduate residency training and continuing medical education.

  • Ability to compose concise and grammatically correct written communication. Exhibit good listening skills including retaining information and asking questions to clarify or expand information. Keep supervisors and/or other staff members informed of issues and/or concerns. Possess a positive attitude and a friendly manner when communicating with others. Express self in an articulate and polite manner in personal interactions and on the telephone.

  • Strong interpersonal and communications skills in order to provide effective leadership for assigned staff, and to interact effectively with physician Program Directors, Residents/Fellows, GME Staff, and a variety of health team members and hospital staff required.

  • Analytical abilities necessary to organize, supervise and evaluate the work of others, to develop, interpret, implement and evaluate policies, procedures, standards and budgets, and to utilize current practice concepts and theories required.

  • Diplomacy and conflict resolution skills.

  • Negotiation skills.

  • Ability to direct/supervise staff personnel.

  • In depth knowledge of hospitals, clinics, campus, various departments and their activities.

  • Knowledgeable in hospital policies including, but not limited to, Human Resources, Graduate Medical Education, Quality Improvement, Medical Records and the Legal Department as they relate to the program, is responsible for the maintenance of and adherence to policies of the program and Boston Medical Center and updating the appropriate hospital departments with regard to staffing changes.

  • Computer proficiency inclusive of the ability to access, enter, and interpret computerized data/information required.