Baptist Health

Key Responsibilities

• • Serve as the institutional official with authority and responsibility for the oversight and administration of all ACGME-accredited programs.
• • Ensure compliance with ACGME Institutional, Common, specialty, and subspecialty program requirements.
• • Act on behalf of the Sponsoring Institution in all matters related to ACGME accreditation.
• • Partner with the GMEC to establish, implement, and monitor institutional GME policies and procedures.
• • Ensure the GMEC effectively reviews program performance, accreditation status, and compliance concerns.
• • Oversee GMEC documentation, including agendas, minutes, and action plans.
• • Review and approve Program Letters of Agreement (PLAs) and ensure appropriate oversight of participating sites.
• • Review and approve institutional and program-level submissions to the ACGME, including applications, changes, and annual updates.
• • Lead institutional preparation for ACGME site visits, reviews, and responses to citations.
• • Ensure systems are in place to monitor and improve the clinical learning and working environment.
• • Oversee institutional processes related to patient safety, quality improvement, supervision, and professionalism involving residents and fellows.
• • Ensure residents and fellows have mechanisms to report concerns related to patient safety, quality of care, mistreatment, or the learning environment.
• • Ensure institutional policies and processes address resident and fellow well-being, fatigue mitigation, impairment, and professionalism.
• • Promote a culture that supports psychological safety, professionalism, and respectful learning environments.
• • Ensure confidential processes exist for reporting and addressing mistreatment or unprofessional behavior.
• • Provide guidance, mentorship, and institutional oversight to Program Directors.
• • Ensure adequate resources, faculty time, and administrative support are available to meet ACGME requirements.
• • Support faculty development related to teaching, evaluation, and accreditation expectations.
• • Ensure institutional GME policies are current, implemented, and reviewed regularly for ACGME compliance.
• • Review institutional and program-level data, including ACGME surveys, duty hour reports, board pass rates, and milestone outcomes.
• • Lead institution-level quality improvement initiatives related to graduate medical education.
• • Serve as the primary contact between the Sponsoring Institution and the ACGME.
• • Collaborate with hospital leadership, medical staff leadership, quality and safety, human resources, and legal/risk management as needed.
• • Represent the institution on GME-related matters with external partners and regulatory bodies.