General Summary

Under general supervision of -GME Management, coordinates, monitors and provides oversight of educational activities related to the compliance of the Graduate Medical Education Programs, in accordance with Accreditation Council for Graduate Medical Education (ACGME) standards as well as published standards from other accrediting organizations, including but not limited to The Joint Commission for Health Care Organizations (TJC).

Principal Responsibilities and Tasks

• The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Working closely with GME management, develops new oversight compliance activities and enhances existing oversight processes to document adequate oversight and monitoring of accreditation standards for the sponsoring institution and its Graduate Medical Education Committee, for greater than sixty residency/fellowship programs.
2. Coordinates and participates in thoughtful and comprehensive internal reviews, serving as an administrative representative during each program's mock review (internal reviews). Develops thoughtful and thorough questionnaires related to these internal reviews, and documents the Review Teams findings and recommendations in well-written and carefully constructed narrative and summary report format. Assists GME management in the dissemination of these reports to the Graduate Medical Education Committee and/or Internal Review Team members.
3. Assists with the collection of data and the preparation and review of documentation for the ACGME Institutional Review. Requires periodic updates from all programs related to concerns identified in internal review and prior site visits.
4. Conducts pre-site visit interviews with key faculty, staff, and residents to assure adequate preparation for external reviews. Assists in the review of completed Program Information Forms prior to seeking the signature of the Chief Medical Officer on these documents. Develops efficient and effective monitoring tools and methodologies that identify opportunities for improvement and promote compliance of programs and the sponsoring institution, thus assuring the Graduate Medical Education Committee fulfills its stringent oversight requirements of the programs and the sponsoring institution.
5. Coordinates institutional wide surveys and meetings, including, but not limited to, those related to Resident Supervision and/or Patient Safety matters, and compiles summary reports, based on these surveys and meetings for the Director and Manager of Compliance - GME. Recommends corrective actions where out of line conditions/trends are indicated.
6. Working closely with GME management, develops and maintains useful and accurate reporting systems about Graduate Medical Education Committee oversight activities, and provides professional
7. presentation of these reports at prescribed intervals to the Graduate Medical Education Committee and/or executive staff and committees as requested/required.
8. Prepares revisions to Graduate Medical Educational policies for review and approval by the Graduate Medical Education Committee. Provides assistance to departmental representatives with development of policies specific to their departmental needs, develops monitoring, auditing tools and summary reports to promote greater compliance with accrediting requirements and regulations. Consults on an ongoing basis on areas of concern with GME management.
9. Keeps up-to-date with laws, regulations, standards and guidelines. Communicates and disseminates this information broadly to departmental/program and institutional leaders, as well as their support personnel and/or residents, and provide guidance and direction where changes are necessary to respond to current requirements.
10. Works closely with School of Medicine faculty and Director of Graduate Medical Education to identify training opportunities at an institutional level (e.g., competency based training) for program faculty and/or residents, to assure greater compliance with accrediting requirements (e.g., ACGME, TJC). Serves as a resource in identifying ongoing education and training needs for program staff and residents and works closely with the Manager - GME to solicit the participation of the appropriate staff in the development of this training.
11. Works to assure that commitment to compliance from all levels of management exists and is maintained by developing strong working relations with Program Directors, Residency Coordinators, and Departmental Administrators. Serves as a resource to these groups in providing guidance and oversight related to compliance with accrediting body requirements.
12. Assures web-based information in MedHub remains current, particularly as it relates to Resident Supervision and procedure privileges. Assists Director and Manager of Compliance - GME by periodically updating the UMMC GME internet page.
13. Assists GME management by promoting other activities that foster compliance. Assures the communication network exists to solicit feedback, evaluate and respond to complaints, problems and issues through any means of communication (calls, e-mails, faxes, mail).
14. On behalf of GME management, collects and compiles the data necessary for the preparation of the annual report for the Medical Executive Committee and the UMMC Board of Director concerning Graduate Medical Education activities.