The following describes the various aspects of the designated job. Some or all of these aspects may be changed over time, with or without notice, at the sole discretion of the Accreditation Council for Graduate Medical Education (ACGME).
Applicants must be currently authorized to work in the United States (US) on a full-time basis. The ACGME will not provide employment sponsorship for this position (e.g., H-1B Visa or other US employment authorization).
Title: Executive Director, Surgical Accreditation
Department: Department of Accreditation, Recognition, and Field Activities
Reports to: Chief Accreditation Officer
Work Schedule: Full Time
The Executive Director, Surgical Accreditation directs the flow and execution of work for the assigned Review Committees and serves as counselor to the members of those Review Committees, as well as to designated institutional officials, program directors, and coordinators on ACGME requirements.
Job Context/Background Information
The ACGME, through its Review Committees, provides accreditation standards (Institutional and Program Requirements) for resident and fellow physician education programs and their Sponsoring Institutions, and monitors adherence with those requirements to ensure consistent delivery of high-quality graduate medical education.
Goals include fostering innovation and improvement in the physician learning environment, increasing accreditation emphasis on educational outcomes, and increasing efficiency and reducing burdensome work often associated with accreditation.
The Review Committees review Sponsoring Institutions or graduate medical education (GME) (residency and fellowship) physician education programs for accreditation purposes. They do this by reviewing extensive information provided by the Sponsoring Institutions and programs, Site Visit Reports prepared by ACGME Accreditation Field Representatives, and other materials relevant to each review. Based on their reviews, the Review Committees issue findings, which may include citations for infractions and inadequacies. ACGME staff members handle the communication and follow-up of Review Committee findings with Sponsoring Institutions and programs.
Each Review Committee meets two to three times per year to review new accreditation applications and currently accredited Sponsoring Institutions or programs scheduled for review. The review schedule is based on institutional and program performance on screening indicators for outcome measurements (e.g., surveys of residents/fellows and faculty members, resident/fellow and faculty member scholarly activity, program changes, Case Logs, and board pass rates) and requests for changes by the programs (e.g., resident/fellow complement, addition of clinical rotation sites). Programs with areas of non-compliance or concerns are reviewed more frequently and may be required to provide progress reports. Between meetings, interim requests for program changes (e.g., temporary changes in the number of residents/fellows) and correspondence from Sponsoring Institutions and programs with issues are processed. In addition, Review Committees periodically revise the Institutional or Program Requirements and Case Log requirements.
Residency/fellowship program directors, faculty members, coordinators, and institutional officials regularly contact the ACGME with questions or concerns. Residents and fellows occasionally contact the ACGME. These interactions are handled by the ACGME staff members assigned to support the Review Committees. Responses may be simple or may require a detailed understanding of the intentions of the accreditation requirements and knowledge of the Review Committee’s past decisions on similar matters. Additionally, the ACGME provides periodic instruction to the institutional and program staff members on how to prepare for accreditation reviews and implement accreditation requirements.
Primary Duties and Responsibilities
Manage/oversee every aspect of Review Committee meeting preparation, including agenda development, preparation, and electronic dissemination of meeting materials; assignment of reviewers and collection of reviews; handling of meeting logistics; and preparing Case Log reports.
Review data in visual software and based on screening criteria or exception reports; examine select program files for details to determine readiness for Committee review or the need for other information.
Ensure the agenda reflects all scheduled reviews and other important issues, and that all needed materials are present.
Check reviewer findings for consistency and adherence to accreditation requirements to identify issues prior to meetings, and confer with Review Committee Chair or reviewers on accreditation recommendations that may not be consistent with the Institutional or Program Requirements and precedents.
Staff Review Committee meetings and work with Review Committee Chairs to execute the agendas; participate in discussions to advise on policies, procedures, and the application of Institutional and Program Requirements and precedents; use data from various sources, such as the Accreditation Data System (ADS) and Spotfire, to generate analyses and support Review Committee decision making; facilitate group consensus on difficult accreditation actions, sometimes through significant discourse; use a solid grasp of the policy implications of decisions and provide input at key points to assist the Committee in making decisions that are in the best interest of both the GME program and the residents/fellows, and adhere to the mission, vision, values, and policies and procedures of the ACGME; guide the maintenance of consistency in Review Committee actions and decisions; record and document material for all citations and other salient meeting information.
Manage/oversee follow-up after Review Committee meetings, including timely completion of Letters of Notification, meeting minutes, review of committee decisions, recording/processing recommendations, producing articles for newsletters and website updates, follow-up for business-related items on the meeting agenda, and following up with programs and institutions.
Go over Review Committee meeting decisions to ensure fairness and consistency in the application of requirements, review data to support every citation, and ensure there is a program requirement related to every citation; maintain consistency in Review Committee output and determine when exceptions are warranted.
Compose initial drafts and oversee timely processing of official accreditation Letters of Notification to the programs to communicate the Review Committee’s accreditation decisions and all related program actions; ensure the letters are accurate, clear, and provide actionable recommendations to Sponsoring Institutions and programs.
Manage/oversee/provide communication with Sponsoring Institutions and programs in the applicable specialties/subspecialties, including responding to questions related to Review Committee meeting decisions and program requirements, as well as communication with those planning and preparing new program applications; communicate on behalf of the Review Committee to the respective stakeholders on issues impacting specialty-/subspecialty-specific accreditation (Case Log implementation/updates, ACGME work hour requirements, interpretation of the Program Requirements, etc.); serve as a resource to institutional and program staff members regarding the accreditation process and preparation for review; oversee the handling of program requests; decide which items need to be reviewed by the Review Committee and which can be handled administratively.
Oversee the provision of support and instruction in the use of ACGME software/applications (e.g., Case Log System, ADS); oversee the development and revisions of Frequently Asked Questions (FAQs) documents related to the applicable Program Requirements; conduct instructional meetings for program and institutional personnel and new Review Committee members as required.
Monitor reports, correspondence, and follow-up with programs to determine what action is required.
Manage the development, revision, and dissemination of assigned specialty and subspecialty Program Requirements and work closely with the ACGME Requirements Development Team to adhere to established formats and deadlines; support the work of Review Committee subcommittees that assist with developing or revising Program Requirements according to the ACGME Committee on Requirements’ established criteria; coordinate with nominating organizations to ensure that ACGME accreditation is consistent with specialty physician board certification requirements.
Oversee the tools for collecting required information such as program applications; facilitate development and acceptance of standardized formats by stakeholders.
Oversee the functioning and development of the administrative staff to support the work of the Review Committees and other related ACGME initiatives; provide training and performance feedback; ensure work is performed to acceptable standards; provide coaching and support to improve these team members’ familiarity and understanding of the Institutional and Program Requirements and ACGME policies and procedures.
Work with other units within and external to the Department of Accreditation, Recognition, and Field Activities for approval of requirements, new subspecialties, Monitoring Committee reports, Case Logs, and related issues; this includes working with specialty boards to obtain board scores and developing new Program Requirements, working with the Applications and Data Analysis team to develop analyses and reports for Review Committee meetings, maintaining ongoing contact with professional specialty organizations regarding requirements and nomination of new Review Committee members, etc.
Serve in various capacities to support the maintenance and improvement of department-wide operations; serve on departmental committees as assigned; lead standardization initiatives and quality assurance and improvement initiatives as assigned; direct and manage the Review Committee administrative staff team to meet departmental quality metrics.
Participate in conferences and meetings, including the ACGME Annual Educational Conference, program director meetings, etc., by submitting abstracts for consideration, developing and making presentations, serving on panels, and meeting with program directors, designated institutional officials, etc.
Ensure that the assigned Review Committees’ specialty information are kept current.
Prepare ACGME Monitoring Committee reports on behalf of the Review Committees; evaluate Review Committee activity through Monitoring Committee Reports.
Prepare and give instructional presentations; oversee provision of orientation, ongoing training, and support to Review Committee members in areas such as the use of ACGME software, applications, and systems, and adherence to ACGME travel and expense policies.
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Education, Knowledge, Skills, and Abilities
PhD or equivalent degree in a relevant discipline strongly preferred with 10 or more years of relevant experience; basic statistical knowledge required.
Strong background and experience in graduate medical education, accreditation, certification systems, program evaluation, or educational research preferred; administration or management experience in a related area required.
Prior experience in an administrative or educational role in a surgical or related program highly desirable.
Proven interpersonal and diplomatic skills, including the ability to work with physicians, act as a liaison with various groups, and achieve consensus with disparate stakeholders; ability to interact credibly with those involved in graduate medical education required.
Must have a demonstrated ability to successfully manage multiple simultaneous ongoing projects.
Must have the demonstrated ability to communicate effectively in writing, and polished verbal and public speaking skills; must be able to prepare well-written correspondence appropriate to ACGME stakeholders (medical professionals in particular).
Must have analytical and conceptual thinking skills, and the ability to clearly communicate analysis and ideas.
Must have experience in and the ability to work with and interpret data to make and justify decisions.
Must have demonstrated management and team-building skills.
Must have demonstrated ability to lead change efforts.
Must have experience developing and delivering presentations to small and large groups virtually and in person.
Must be familiar with higher education programs and their structure, application, and accreditation.
Must have a comfortable familiarity with use of the Internet, web-based programs, online meeting software, and computer software applications of Word, Power Point, and Excel.
Position requires significant use of standard office equipment, such as a personal computer, keyboard, mouse, copier, fax machine, telephone, etc.
Most of the work of the Executive Director, Surgical Accreditation is normally done in the ACGME office with the typical physical demands of an office environment. During the COVID-19 pandemic, ACGME employees are working remotely until further notice. The Executive Director, Surgical Accreditation will need to be able to efficiently and effectively work remotely.
This position generally requires significant travel outside the office. Candidates must be willing and able to travel as needed to attend about 10 to 12 out-of-state meetings per year, with duration of one to seven days per meeting, typically including evenings and weekends.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.
While performing the duties of this job, the Executive Director, Surgical Accreditation:
Will frequently be required to sit in meetings for long periods of time.
Will frequently be required to participate in training via Zoom or other video conferencing platforms.
Will be required to listen to, participate in, lead, understand, record, and summarize complex discussions during and following Review Committee meetings.
Will be required to review large quantities of hard copy and electronic written information, and to review the hard copy and electronic written work product of others, including layout and appearance.
Will be required to travel each year throughout the United States.
An Equal Opportunity/Affirmative Action/Pro Disabled and Veteran Employer
About Accreditation Council for Graduate Medical Education (ACGME)
The Accreditation Council for Graduate Medical Education (ACGME) is a private, non-profit, professional organization responsible for the accreditation of nearly 9,000 residency education programs and about 700 institutions that sponsor these programs in the United States. Residency programs are responsible for educating over 116,000 resident physicians in 135 specialties and subspecialties. The ACGME's mission is to improve health care by assessing and advancing the quality of resident physicians’ education through exemplary accreditation.