Post on 27-May-2018
How an IRAT (Institutional
Requirements Administrative
Team) Could Help You
May 5, 2017
Krista Lombardo-Klefos, MBA
Accreditation Manager
Cleveland Clinic
Disclosures
No conflicts of interest to report
All IRAT work is discussed with the
DIO and GMEC
Objectives
• Understand and have the ability to explain
what a functional workgroup is
• Learn how the Cleveland Clinic GME Office
is overseeing ACGME Institutional and
Program Requirements
• Review examples of what the IRAT has
been able to accomplish since 2013
• Reflect on ways in which functional
workgroups could be implemented in your
institution
80 non accredited
programs
15 GME office
personnel
1,187 trainees
Numerous ACGME
requirements and
policies
157 Program
Directors
CCHS Integration
Cleveland Clinic’s Story
• December 2011- Institutional Site Visit
Notification letter
- 1 Accreditation Manager
• How to complete the Institutional Review
Document by April 2012?
• Utilize subject matter experts within GME
department
• Assign tasks
• Meet to discuss
1,187
pages
Ongoing ACGME Compliance
• Surveys
• Milestone Reporting
• Annual ADS Update
• Deans Letter
• Policies
• Goals and Objectives
• Program Letters of Agreement
• Program Director protected time
• Annual Notification Letters
• Accreditation Fees
List can go on and on AND is getting increasingly bigger…….
IRAT Institutional Requirements Administrative Team
• Successful Site Visit
- Dividing work amongst team
- Recognized need to formalize
• ACGME Announcement of the Next
Accreditation System (NAS)
- New Institutional and Common Program
Requirements
- Clinical Learning Environment Review
- Self-Study Visits
Functional Workgroup
Merriam Webster says…
“a group of people who work together;
an organized group of coworkers within a
business or other organization”
“used to contribute to the development or
maintenance of a larger whole”
Lori Smith, MBAAdministrative Director
Elias I Traboulsi, MD, MEdDIO
Nicole Fennell, MBACommittee Coordinator
Kathy Baker, MEdRMS Program Manager
Krista Lombardo-Klefos, MBAAccreditation Manager IRAT Lead
Anna Zulia, MEdEnterprise Liaison
DIO
Ultimately responsible for GME accreditation
activities
AM
• Project Manager for ACGME Initiatives
• IRAT Lead
AD• Administrative
Oversight
• Educational Resource for GME Community
CC• Management of
GMEC and subcommittees
• Arranges professional development education
EL• Health System
activities
• PLA compliance / reimbursement optimization
RMS
• Data analytics
• System utilization and training
GMEC
and
subcommittees
GME Office
Personnel
GME office
personnel
PD/PCsHouse Staff
Association
Major Accomplishments
2012 2013 2014 2015 2016
• Institutional Site Visit
•GSR Policy/Procedure
• Institutional APE Template (program)
•CLER Visit
•Milestone Toolkit & Education
•AIR
•CLER Visit
•Self-Study Visit (program)
•RMS Functionality
•CLER Pursuing Excellence Application
Ongoing Projects
• Action Plans
- AIR
- CLER
• CLER Readiness
• Pursuing Excellence
• Incorporating 2017 CPRs
• Cleveland Clinic Health System
Integration
How the IRAT Functions
• Weekly Huddles
- Thursdays at 10:00am
- Round-robin style
- DIO present
• Monthly Meetings
- 3rd Thursday 1:30-3:30pm
- Formal agenda
- Brainstorming process improvement
Ideas that worked
1. Sharing of information
- DIO and GMEC receive in time
updates
2. Responsibility Listing
- Owning tasks
3. Project Management
- AIR
- CLER
Responsibility Listing Responsibility Lead
ACGME Annual Resident and Faculty Survey Accreditation Manager
ACGME Pursuing Excellence in Clinical Learning Environments Accreditation Manager
Annual Institutional Review (AIR) Report Accreditation Manager
Annual Program Evaluation (APE) Process Accreditation Manager
CCHS Integration Enterprise Liaison
Change/New Program Applications Accreditation Manager
Clinical Learning Environment Review (CLER) Accreditation Manager
Duty Hours - Institutional Quarterly Review GME Committee Coordinator
GMEC GME Committee Coordinator
GMEC QPS Subcommittee GME Committee Coordinator
GMEC Special Review Accreditation Manager
Institutional and Program Policies Accreditation Manager
Institutional Site Visit/Self-Study Accreditation Manager
Participating Sites/Affiliation Agreements Administrative Director
Program Director/ Coordinator Meetings/Webinars GME Committee Coordinator
Program Goals and Objectives Administrative Director
Program Site Visits/Self-Study Accreditation Manager
Residency Management System RMS Manager
Resident Appeals, Salary/Benefits Administrative Director
RRC Notification Letters Accreditation Manager
Semi-Annual Evaluations/Deans Letter RMS Manager
webADS Accreditation Manager
AIRInitiated 2014
• Designed new process
• Assigned sections
- RMS – institutional graphs
- CC – GMEC and subcommittee data
- AM – draft compilation of report
• Team presentation of work to DIO
- 62 page report
• Action Plan
- Work with GMEC members on items
CLER
• Develop a timeline and action plan
- Offered choice of task
- Full transparency
• 2014 & 2015 successful visits
- GME Community was engaged
- Tasks successfully completed on time
• After action review to see what can go
better next time
Challenges
• Work in addition to day-to-day job
responsibilities
• Disengaged team members
• Turnover
What the Future Holds
• Re-organization
• Assisting programs with
- Program Letters of Agreements
- Goals & Objectives
- Policies
• Incorporation of the new CPRs
- Wellness
• Anything else ACGME brings our way….
Additional Ideas for
Functional Workgroups
• GME Offices
- Technology Team
- HR Onboarding Team
• Programs
- Self-Study Visit
• GME Community
- GME & PC
• Anywhere…..
Self-Study Visit Diagnostic Radiology - 2016
• Core and subspecialty programs need
to work together
• Combine your Self-Study Group
• PDs and PCs meet once a month
• Overall SWOT for specialty
- Parse out into sub-specialized area
• Review and provide feedback on each
others Self-Study summary template
GME-PACInitiated 2016
“To promote GME program compliance and
develop standards to ensure a quality
educational environment within the
Cleveland Clinic Health System”
- Creating awareness of the PC role
- Providing a support system
- Define and disseminate best practices
• Monthly meetings
• Tracked projects
Q/A
Q/A
• Does anyone already have a Functional
Workgroup?
• Are there any areas in your institution
where a Functional Workgroup would
be valuable?
Every resident deserves world class training.