III - Partners HealthCare



Partners Graduate Medical Education: Program Director Job DescriptionThe template offer letter and job description below should be customized to reflect the specific needs of individual programs and the sponsoring department, and to comply with the ACGME program requirements.Program Director Job Description [Template]SECTION IThe institution has determined that the following elements are essential to fulfilling the Program Director role. These, and additional responsibilities as defined by the Department Chair, should be included in the final job description, with added specifications as appropriate:The program director will have regular meetings that focus on oversight and optimization of the program. Participants may include the program director, associate/assistant program director, program coordinator, department chair, and representatives of the faculty and trainees. (Example text: “The program director will convene two meetings each year, with at least three faculty or division chiefs, and four-six residents as well as the program coordinator, that will focus on program improvement. Minutes will be reviewed with the Department Chair.”)The educational effectiveness of a program must be evaluated at least annually in a systematic manner via a process determined and led by the program director.Representative program personnel (i.e., at least the program director, representative faculty, and one resident) must be organized to review program goals and objectives, and the effectiveness with which they are achieved. This group must conduct a formal, documented meeting at least annually for this purpose. In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution, and the residents’ confidential written evaluations. If deficiencies are found, the group should prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting.The program should use resident performance and outcome assessment in its evaluation of the educational effectiveness of the residency program. Performance of program graduates on the certification examination should be used as one measure of evaluating program effectiveness. The program should maintain a process for using assessment results together with other program evaluation results to improve the residency program.The program director must provide a final evaluation for each resident who completes the program. This evaluation must include a review of the resident’s performance during the final period of education, and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently. The final evaluation must be part of the resident’s permanent record maintained by the institution.The program director must confer with one of the institution’s GME directors before taking formal adverse action and/or before placing a trainee on probation.The program director is responsible for ensuring that affiliation agreements required by ACGME are completed, updated as needed, and kept on file in the department.The program director is responsible for development and periodic updating of a written curriculum, with detailed goals and objectives for each rotation and/or educational activity.SECTION IIThe Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements also outline some activities which are assigned as responsibilities of the directors of ACGME-accredited GME programs. These are listed below, and should be added to the list of program director responsibilities as defined by the Department Chair (Example text: “The program director will issue a written contract to the xxxx residents annually”)program directors must assure that residents are provided with a written agreement of appointment/contract outlining the terms and conditions of their appointment to a programprogram directors must ensure that residents are informed of and adhere to established educational and clinical practices, policies, and procedures in all sites to which residents are assignedprogram directors must conduct annual program improvement efforts that consider(1) resident performance using aggregated resident data;(2) faculty development;(3) graduate performance including performance of program graduates on the certification examination; and,(4) program quality.SECTION IIIThe ACGME Common Program Requirements (CPR Effective July 1, 2017) outline a number of specific PD responsibilities (shown in italics, below) which must be addressed in the institution’s job requirements for directors of ACGME-accredited GME programs. Additional requirements may be specified by each Residency Review Committee (RRC), and should also be incorporated into the final job description. While most of the text of the CPR can be copied “as is”, the final job description should be individualized to the program and circumstance.Incorporation of program-specific requirements is essential since these may specify minimums regarding the PD’s time commitment, salary, and/or administrative support, and may outline additional responsibilities.ACGME Common Program Requirements1. There must be a single program director with authority and accountability for the operation of the program. (Example text: “The program director will have sole authority over the xxxx program and be accountable to the Department Chair for the operation of the program, regardless of the training site.”)[include additional criteria as further specified by the RRC]2. The program director should continue in his or her position for a length of time adequate to maintain continuity of leadership and program stability. (Example text: “The program director will be expected to remain in this position for at least xxxx years, overseeing the graduation of at least two classes.”)[include additional requirements as further specified by the RRC]3. Qualifications of the program director must include a) requisite specialty expertise and documented educational and administrative experience acceptable to the Review Committee; b) current certification in the specialty by the American Board of ________, or specialty qualifications that are acceptable to the Review Committee; and, c) current medical licensure and appropriate medical staff appointment.[include additional qualifications as further specified by the RRC]4. The program director must administer and maintain an educational environment conducive to educating the residents in each of the ACGME competency areas. The program director must:a) oversee and ensure the quality of didactic and clinical education in all sites that participate in the program; b) approve a local director at each participating site who is accountable for resident education;c) approve the selection of program faculty as appropriate;d) evaluate program faculty;e) approve the continued participation of program faculty based on evaluation;f) monitor resident supervision at all participating sites;g) prepare and submit all information required and requested by the ACGME. This including but not limited to the program application forms and annual program updates to the ADS, and ensure that the information submitted is accurate and complete; h) ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and implemented by the sponsoring institution; i) provide verification of residency education for all residents, including those who leave the program prior to completion; j) implement policies and procedures consistent with the institutional and program requirements for resident duty hours and the working environment, including moonlighting, and, to that end, must: (1) distribute these policies and procedures to the residents and faculty; (2) monitor resident duty hours, according to sponsoring institutional policies, with a frequency sufficient to ensure compliance with ACGME requirements; (3) adjust schedules as necessary to mitigate excessive service demands and/or fatigue; and, (4) if applicable, monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue. k) monitor the need for and ensure the provision of back up support systems when patient care responsibilities are unusually difficult or prolonged; l) comply with the sponsoring institution’s written policies and procedures, including those specified in the Institutional Requirements, for selection, evaluation and promotion of residents, disciplinary action, and supervision of residents;m) be familiar with and comply with ACGME and Review Committee policies and procedures as outlined in the ACGME Manual of Policies and Procedures; n) obtain review and approval of the sponsoring institution’s GMEC/DIO before submitting information or requests to the ACGME including: (1) all applications for ACGME accreditation of new programs; (2) changes in resident complement; (3) major changes in program structure or length of training; (4) progress reports requested by the Review Committee; requests for increases or any change to resident duty hours; (6) voluntary withdrawals of ACGME-accredited programs; (7) requests for appeal of an adverse action; (8) appeal presentations to a Board of Appeal or the ACGME. o) obtain DIO review and co-signature on all program information forms, as well as any correspondence or document submitted to the ACGME that addresses: (1) program citations, and/or (2) request for changes in the program that would have significant impact, including financial, on the program or institution. [include additional requirements as further specified by the RRC]SECTION IVAdditional specialty-specific requirements for Program Director responsibilities as outlined in the ACGME Program-specific requirements not already included:[These must be incorporated into the job description.]SECTION VDepartmental requirements not addressed above include:[specify, if any]Sample Offer LetterDear ______,It is a pleasure to appoint you to the position of Director of the BWH/MGH/PHS [sub/specialty] Residency/Fellowship program, as of [date]. As Program Director (PD), you will have authority and accountability for the operation of the program. Specific responsibilities include those detailed in the attached job description.In order to carry out these responsibilities, and to develop and implement a vision for the ___ program, approximately __% of your effort [or: __ hours/week] will be devoted to GME program leadership. Salary support of $___ will be provided for this role and this support is not dependent upon or related to clinical income [or: protected time will be provided by (?giving up x, y, and z) while your salary is maintained at the current level]. In addition, the department will support dues for your membership in the national program directors’ association and travel to a meeting of that association each year.To assist you in overseeing the residency/fellowship program, the department will provide the following support staff:Associate Program Director/s:Program Coordinator:Administrative assistant/secretary:(other):Program Directors also play an important institutional role. Your responsibilities outside of the department include:Serving as the key contact and responsible person linking the institution’s GME leadership and infrastructure with the training program;Attending meetings of the hospital education committee (and the Partners Education Committee, if elected);Attending program director workshops, which are designed as professional development opportunities for program directors;Responding to periodic data requests and surveys from the institution and external agencies (providing demographic information, documentation of compliance with various requirements, follow up to accreditation letters or internal review reports, etc);Participating in a detailed, periodic program review by an institutional internal review committee;Serving on internal review committees for other GME programs; Serving on task forces or subcommittees convened by the hospital-based or Partners GME committee.Once you have assumed the role, we will discuss the nature and timing of the evaluation and feedback that I will provide to you. This will occur at least annually.In accordance with ACGME requirements, the institution’s education committee has approved this appointment.I look forward to working with you to optimize our _________ program. With best wishes,[Chair] ................
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