Manager, LCME Accreditation & Continuous Quality Improvement

Case Western Reserve University is committed to providing a transparent estimate of the salary range available for this position at the time of its posting. The salary range is between $52,705 and $66,672, depending on qualifications, experience, department budgets, and industry data.

Employees receive more than just a paycheck. University employees enjoy a comprehensive benefits package that includes excellent healthcare, retirement plans, tuition assistance, paid time off, and a winter recess.

POSITION OBJECTIVE

Responsible for organizing, coordinating, and administering the School of Medicine's Liaison Committee on Medical Education (LCME) accreditation processes. The LCME accreditation cycle requires quality assurance to determine whether an MD program meets established national standards. This process fosters institutional and programmatic improvement on a continuous loop. To achieve and maintain accreditation, a medical education program leading to the MD degree in the United States must meet the accreditation standards. The manager is responsible for accruing evidence, providing documentation, and updating and synthesizing data to facilitate accreditation and continuous quality improvement efforts for the School of Medicine. This individual will also develop and monitor policies and procedures related to medical education accreditation and continuous quality improvement. The manager will be an integral accreditation advisor for the medical school's accreditation initiatives. The manager plans, implements, directs, and facilitates activities that reinforce the School of Medicine's ability to achieve and remain a successful LCME-accredited educational organization.

Essential Functions

• Provide expert guidance on activities associated with the accreditation process. Lead and coordinate the evolving Liaison Committee on Medical Education (LCME) accreditation standards, overseeing the preparation, refinement, and timely submission of School of Medicine documents to the committee. Oversee processes for monitoring compliance with accreditation standards and within the continuous quality improvement plan; document continuous quality improvement initiatives for the LCME and internal processes; lead and coordinate regulatory LCME site visits, ensure all LCME accreditation requirements are documented and processed in accordance with established timelines, including completion of all reporting requirements and preparation for cyclical accreditation reviews and site visits. (30%)
• Effectively direct activities related to the continuous quality improvement plan and LCME. This includes but is not limited to communications, required reporting to relevant stakeholders, continuous quality improvement data collection and implementation. Related such tasks include, maintaining document storage, data collection, documentation revisions and submissions, and version control procedures. Develop content related to the accreditation/ continuous quality improvement processes and site visit information for internal and external-facing communications. Advise and collaborate with internal and external partners on continuous quality improvement / accreditation processes. Develop and maintain specialized training to ensure faculty and staff stay abreast of compliance and accreditation requirements. (20%)
• Manage, monitor, and update data collection, presentation, and accuracy for accreditation tables. Manage the timeliness of the self-study process, including but not limited to the mock site visit, the LCME site visit, and accreditation-related meetings. Proof all aspects of the LCME data collection instrument (a document of 1,000 to 1,500 pages), including follow-up reports, accreditation updates, progress reports, and responses to citations. Serves as the principal administrative contact for the accreditation/continuous quality improvement team. Serve as a key member of LCME-related committees. (20%)
• Collect, analyze, and synthesize pertinent accreditation and quality improvement data, including relevant internal evaluation/continuous quality improvement data and independent student analysis and graduation questionnaire results. (15%)
• Responsible for the development, maintenance, organization, and publication of educational policies, ensuring that all practices adhere to the standards of accreditation. This responsibility involves working closely with a diverse group of academic, administrative, and technical stakeholders to foster alignment across departments and ensure policies are up to date, approved, accurate, and available. (10%)
  
  
  

Nonessential Functions

In conjunction with the director of operations and office of general counsel, assists with the negotiation, management, and ongoing maintenance of affiliation agreements and/or memorandum of agreement with external educational sites, ensuring compliance with accreditation requirements. Serve at the primary point of contact for managing the affiliation agreement repository. (5%)

Perform other duties as assigned within medical education and accreditation. (

CONTACTS

Department: Continuous contact with all faculty and staff, including the vice dean for medical education and director of continuous quality improvement, to organize and communicate accreditation needs and performance improvement efforts.

University: Frequent contact with the medical school dean, chief of staff, vice dean for finance, associate dean for space and facilities for accreditation purposes, information sharing, and data collection.

External: Regular contact with LCME staff and reviewers to solicit and provide information before, during, and after the formal LCME site visits.

Students: Moderate contact with students for surveys and various medical education committees.

SUPERVISORY RESPONSIBILITY

No direct supervisory responsibilities. Will delegate committee logistical tasks to the vice dean's executive assistant.

Qualifications

Experience: 3 to 5 years of experience. In-depth knowledge of LCME or similar accreditation processes (e.g., ACGME), procedures, timelines, standards and compliance issues, continuous quality improvement processes, and/or project management experience.

Education/Licensing: Bachelor's degree required. Master's degree preferred.

Required Skills

• Knowledge of program level and institutional level accreditation requirements and processes. Knowledge of LCME is preferred but not required.
• Knowledge of data collection, analytics, and decision-making tools to inform strategic planning and continuous quality improvement efforts.
• Skills in project management at all phases regardless of where in process.
• Proficient in Microsoft Windows, Microsoft Office: Excel, Word, and PowerPoint, and web navigation techniques. Data collection and presentation skills (Qualtrics). Preference for basic statistical packages.
• Superior interpersonal verbal and written communication skills in interactions with students, faculty, administrators, and outside agencies. Ability to interact with colleagues, supervisors, and customers face to face.
• Ability to communicate effectively verbally and written, including technical writing.
• Skills to coordinate efforts of multiple groups.
• Ability to commit to cultural diversity and equal opportunity.
• Experience with data collection, database management, and data analysis.
• Demonstrated history of successful support, education, and advocacy for all students, aligned with the values, mission, and messaging of the university, while adhering to the staff policy on conflict of commitment and interest.
• Ability to interact with colleagues, supervisors, and customers face to face.
• Proven organizational skills, including organizing and managing multiple projects and processes simultaneously.
  
  
  

WORKING CONDITIONS

General office environment. May be asked to work a fluctuating schedule. Evening hours may be necessary. This position may be eligible for the staff hybrid work program pending approval.

This position is eligible for hybrid work arrangement up to two remote days per week at the discretion of the department. New employees may begin a hybrid schedule upon approval from the supervisor, successful completion of an orientation period and signing the remote work checklist certification form.

Case Western Reserve University is an equal opportunity employer. All applicants are protected under federal and state laws and university policy from discrimination based on race, color, religion, sex, sexual orientation, gender identity or expression, national or ethnic origin, protected veteran status, disability, age and genetic information.

Case Western Reserve University complies with the Americans with Disabilities Act regarding reasonable accommodations for applicants with disabilities. Applicants requiring a reasonable accommodation for any part of the application and hiring process should contact the CWRU Office of Equity at 216-368-3066 to request a reasonable accommodation. Determinations as to granting reasonable accommodations for any applicants will be made on a case-by-case basis.