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.