Documenting Program Director, Faculty, and Medical Director Qualifications for CAAHEP Accreditation

Your self-study "documents how the program meets each of the Standards as outlined in the Standards and Guidelines document for the applicable profession," per CAAHEP's accreditation process [1]. Most coordinators build the curriculum and outcomes sections carefully; the personnel section is usually the part that gets rebuilt from memory every cycle — transcripts, certificates, appointment letters, and a mental model of who holds which license.

That section is worth more than it looks. The site visit team verifies "information and documentation provided in a program's self-study" through "documentation and facilities review, and meetings with students, graduates, faculty, administration, and advisory committee members" [1]. The people who run the program are evidence, too. This post lays out what your CoA's Standards actually require of your program director, medical director, and faculty — and how to keep the files current so self-study becomes a verification instead of an excavation.

The Common Core: What Every CoA's Standards Require

CAAHEP standards combine common elements with discipline-specific requirements [2], and the personnel section shows it. The respiratory care, emergency medical services, and medical assisting standards (and the sonography and assistive technology standards we reviewed) all open their personnel section with the same requirement: the sponsor "must appoint sufficient faculty and staff with the necessary qualifications to perform the functions identified in documented job descriptions and to achieve the program's stated goals and outcomes" [3] [4] [5].

What follows is a list of minimum positions that varies by discipline. Respiratory care requires a program director, clinical coordinator, medical director, and faculty/instructional staff [3]. Emergency medical services requires "Program Director, Medical Director, Faculty/Instructional Staff" [4]. Medical assisting requires a program director, faculty/instructional staff, and a practicum coordinator [5].

Two implications are worth writing down. First, the anchor is the documented job description: the Standards define qualifications against the functions in the job description, so the job description is part of the evidence, not an HR afterthought. Second, people are resources: in the respiratory care standards, "Faculty" is item one on the list of program resources, ahead of curriculum and finances [3].

Program Director: One Role, Five Different Floors

Each of the five standards reviewed here requires a program director responsible for the program as a whole; respiratory care, EMS, and medical assisting use the words "all aspects of the program". But the qualification floor varies by discipline, and it's a mistake to assume a neighboring program's floor applies to yours.

• Respiratory care: full-time; a registered respiratory therapist; holds "such professional license or certificate as is required by the state"; a minimum master's degree; and documented education or experience in instructional methodology. The guideline recommends at least four years of experience as a registered respiratory therapist, including two years in clinical practice and two years teaching in an accredited program [3].
• Emergency medical services: a minimum bachelor's degree to direct a paramedic program (associate's for an AEMT program); documented education or experience in instructional methodology; "academic training and experience equivalent to that of a paramedic"; experience in prehospital emergency care; and knowledge of the National EMS Scope of Practice and National EMS Standards. A master's degree is recommended [4].
• Medical assisting: an employee of the sponsoring institution; a minimum associate degree; credentialed in good standing in medical assisting by an organization whose credentialing exam is accredited by NCCA, ANSI, or ISO; medical or allied health education or training; experience in the profession; and documented education in instructional methodology [5].
• Diagnostic medical sonography: an appointed faculty member or institutional equivalent; a minimum baccalaureate degree; the appropriate credential for the concentration offered; documented experience in supervision, instruction, evaluation, student guidance, and educational theories and techniques; and at least two years of clinical experience as a registered sonographer. A master's degree is preferred [6].
• Assistive technology: a minimum bachelor's degree; at least three years of relevant professional experience; a background in education theory and practice; and a credential from a related profession [7].

The pattern across most of the five: a profession-specific credential (or, for EMS, equivalent training and experience), a degree floor that ranges from associate to master's, and documented education or experience in teaching methods. Your CoA's Standards document is the only one that counts for your program — extract the personnel section once and keep it as a reference.

Medical Director: Only Where Your CoA Requires One

Not every CAAHEP profession has a medical director. The medical assisting and assistive technology standards we reviewed contain no medical director requirement [5] [7]. Diagnostic medical sonography uses a different title: a "medical advisor," who must be a licensed physician certified by the American Board of Medical Specialties with relevant experience and knowledge in sonography, and who provides guidance that the medical components of the curriculum meet current acceptable performance standards [6]. Where the role exists, it's defined by specific responsibilities, not just the title.

The emergency medical services standards are the most explicit: the medical director is listed as a minimum position, and must be a "physician currently licensed and authorized to practice in the state in which the program is located, and board certified or the equivalent," with training or experience in out-of-hospital emergency care — including medical direction and quality improvement — and knowledge of EMS education "including professional, legislative and regulatory issues." Board certification in EMS Medicine or Emergency Medicine is recommended [4]. The responsibilities run to review and approval of educational content across didactic, laboratory, clinical, field, and capstone experiences; approval of the required minimum numbers of patient contacts and procedures; review of the instruments used to evaluate students; review of each student's progress; and assuring the competence of each graduate in the cognitive, psychomotor, and affective domains [4].

The respiratory care standard requires a licensed physician who holds board certification "in a specialty relevant to respiratory care" and has the knowledge and skills to advise program leadership on the clinical and academic aspects of the program; ABMS or AOA board certification is recommended [3].

One clause deserves special attention: EMS adds that when a program designates an Associate Medical Director, the medical director "must specify the delegated responsibilities" [4]. In other words, the delegation memo is part of the evidence file, not an administrative formality.

Faculty and Clinical Instructors: Designated, Qualified, Documented

The common requirement is that "for all didactic, laboratory, and clinical instruction to which a student is assigned, there must be a qualified individual(s) clearly designated by the program to provide instruction, supervision, and timely assessments of the student's progress in meeting program requirements" [3]. The word designated does real work here: every assigned course, lab, and clinical rotation needs a named, qualified person behind it.

The depth of the qualification language varies by discipline. Respiratory care requires faculty to be "effective in teaching and knowledgeable in subject matter as documented by appropriate professional credential(s)/certification(s), education, and experience in the designated content area" [3]. Medical assisting adds documented education in instructional methodology [5]. Diagnostic medical sonography requires faculty to possess appropriate credential(s) for the learning concentration they teach [6]. Assistive technology requires a bachelor's degree, at least three years of related field experience — including one year providing services to clients — and a professional registration, license, or certification [7].

On the clinical side, the respiratory care standard's clinical coordinator must ensure orientation of "the personnel who supervise or instruct clinical students at clinical sites" and that clinical instructors and preceptors are "trained in student evaluation, including inter-rater reliability" [3]. Those orientation and training records belong in the same evidence family as the clinical affiliate agreements covered in our post on preceptor records.

A Documentation System That Holds Up Between Reviews

The Standards don't just list qualifications — they define how the evidence is anchored. Four moves keep the personnel section verification-ready all year:

1. Anchor on the documented job description. The Standards tie qualifications to "functions identified in documented job descriptions" [3]. Keep one current job description for each required position — program director, clinical coordinator, medical director, faculty, preceptors. When responsibilities change, update the job description before the next hire so the file shows the function and the qualification side by side.
2. Build a per-person qualification file. Degree, credential with expiry, license with jurisdiction and expiry, and documented education or experience in instructional methodology. The medical assisting standard spells out what counts as instructional-methodology documentation: "completed workshops, in-service sessions, seminars, or completed college courses on topics including, but not limited to, learning theory, curriculum design, test construction, teaching methodology, or assessment techniques" [5].
3. Give the medical director a file of their own. License, board certification, an appointment letter specifying responsibilities, and a record of the review-and-approval activities the standard assigns — content approvals, patient-contact minimums, evaluation instruments. If an Associate or Assistant Medical Director is designated, include the memo specifying delegated responsibilities (EMS requires this for an Associate Medical Director [4]).
4. Run the annual resource assessment over the people, not just the budget. The respiratory care standard [3] requires the program to "at least annually, assess the appropriateness and effectiveness of the resources," with faculty as item one on that list — the results become "the basis for ongoing planning and change," an action plan is developed when improvements are identified, and implementation is documented. Our resource assessment post covers the mechanics.

When self-study arrives, each CoA's template asks you to document how the program meets each standard — the personnel section should be a verification exercise, not an excavation. And when a program director or medical director leaves, the file moves with the role, not out the door.

Where to Go Next

• Advisory Committees and Resource Assessment — the two obligations that sit right next to personnel in the Standards.
• Clinical Affiliate Agreements and Preceptor Records — the clinical-side half of the same evidence family.
• How to Prepare for a CAAHEP Site Visit — what the visiting team actually does with all of this documentation.

References

1. CAAHEP, "Accreditation Process," CAAHEP. [Online]. Available: https://www.caahep.org/program-directors/accreditation-process
2. CAAHEP, "Standards and Guidelines," CAAHEP. [Online]. Available: https://www.caahep.org/program-directors/standards-and-guidelines
3. JRCRC / CAAHEP, "Standards and Guidelines for the Accreditation of Educational Programs in Respiratory Care" (effective 2/1/2022; technical updates 10/2023, 1/2025), CAAHEP. [Online]. Available: https://cdn.prod.website-files.com/5f466098572bfe97f28d59df/67a10d55f57c59254c43ff7a_RCStandardsApproved1-20-22_update1-27-25.pdf
4. CoAEMSP / CAAHEP, "Standards and Guidelines for the Accreditation of Educational Programs in the Emergency Medical Services Professions" (effective 1/1/2024), CAAHEP. [Online]. Available: https://cdn.prod.website-files.com/5f466098572bfe97f28d59df/66d76a9ce660ce070afd1878_EMSPStandardsApproved3-17-23_Update2024-08-14.pdf
5. MAERB / CAAHEP, "Standards and Guidelines for the Accreditation of Educational Programs in Medical Assisting" (effective 4/4/2022; technical updates 3/2026), CAAHEP. [Online]. Available: https://cdn.prod.website-files.com/5f466098572bfe97f28d59df/69c2e37dca2a53b953dc2023_MAStandardsApproved3-18-22_Update3-23-26.pdf
6. JRC-DMS / CAAHEP, "Standards and Guidelines for the Accreditation of Educational Programs in Diagnostic Medical Sonography" (revised 2020), CAAHEP. [Online]. Available: https://cdn.prod.website-files.com/5f466098572bfe97f28d59df/66d868f5efaed6e08a5176ba_DMSStandardsApproved9-18-20_Update2024-09-03.pdf
7. CoA-RESNA / CAAHEP, "Standards and Guidelines for the Accreditation of Educational Programs in Assistive Technology" (adopted 2016), CAAHEP. [Online]. Available: https://cdn.prod.website-files.com/5f466098572bfe97f28d59df/67a10c25f3c503efe605da1a_ATStandardsApproved9-16-16_update1-27-25.pdf