The Complete Guide to Continuous GME Accreditation

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The Complete Guide to Continuous GME Accreditation

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Available July 2017

The Complete Guide to Continuous GME Accreditation

Kathy Baker, M.Ed. 
Nicole Fennell, MBA 
Krista Lombardo-Klefos, MBA 
Lori Smith, MBA 
Anna M. Zulia, M.Ed. 

The Complete Guide to Continuous GME Accreditation offers comprehensive coverage of the ACGME’s Next Accreditation System with a deep dive into Milestones, Annual Program Evaluation, and the Clinical Learning Environment Review (CLER). 

Insight, guidance, and how-to instructions from the Cleveland Clinic's GME office provide readers with the foundational knowledge to successfully navigate a CLER visit. The authors, Kathy Baker, M.Ed.; Nicole Fennell, MBA; Krista Lombardo-Klefos, MBA; Lori Smith, MBA; and Anna M. Zulia, M. Ed., have undergone two CLER visits at the Cleveland Clinic, and they bring their experience to life in this in-depth guide. They will provide readers with foundational knowledge about the CLER, including definitions, background, and steps to prepare for an on-site visit. Readers will also receive best practices to maintain their program’s accreditation with guidance on the Common Program Requirements, Milestones, and annual surveys and evaluations. 

This book will help you: 

  • Learn how to meet the requirements to maintain institutional accreditation 
  • Discover best practices to plan for the CLER visit, host site visitors, and use the CLER report for continuous improvement 
  • Maintain your program’s accreditation with guidance on the Common Program Requirements, Milestones, and annual surveys and evaluations 
  • Recognize the roles and responsibilities required to meet the goals of a successful learning and work environment 


About the Authors: 

Kathy Baker, M.Ed., graduate medical education program manager, Cleveland Clinic 
In her role, Baker serves as the residency management system manager and is responsible for the overall technology/systems strategy. Baker develops/provides training opportunities to residents/fellows, faculty, and program coordinators and supports various initiatives throughout the department and institution. She previously served as a database manager, where she specialized in data integrity and provided ongoing training for program coordinators on various applications, including the Electronic Residency Application Service and National Resident Matching Program. Baker holds a Bachelor of Science in Exercise Physiology from Ohio Northern University and a Master of Education in Adult Learning and Development from Cleveland State University.

Nicole Fennell, MBA, GME committee coordinator, Cleveland Clinic 
Fennell received her bachelor’s degree from Kent State University and her master’s degree from University of Phoenix. She has been working in graduate medical education at the Cleveland Clinic since 2015. In her current role, she manages the graduate medical education committee (GMEC) and its subcommittees, including the Program Improvement Plan Subcommittee, the Quality and Patient Safety Subcommittee, and the Assessment Subcommittee. Additionally, she is an active member in the Institutional Requirements Administrative Team and assists the accreditation manager with accreditation-related activities. Fennell has co-authored poster presentations and had two abstracts accepted for the Association for Hospital Medical Education (AHME) meeting—“Graduate Medical Education Program Advisory Council (GME-PAC)…Collaborate and Communicate,” and “Institutional Requirements Administrative Team (IRAT) – Amplified Oversight.”

Krista Lombardo-Klefos, MBA, graduate medical education accreditation manager, Cleveland Clinic 
Lombardo-Klefos received her bachelor’s degree from Bowling Green State University and her master’s degree from Cleveland State University; she has been working in graduate medical education at the Cleveland Clinic since 2008. In her current role, she manages the accreditation activities of the training programs and provides education consulting services to the DIO, GMEC, program directors, and program coordinators regarding the ACGME requirements. She also serves as the project manager for the ACGME Clinical Learning Environment Review Visit and Pursuing Excellence in Clinical Learning Environments initiative. Lombardo-Klefos has given numerous local and national presentations, including for the ACGME and AHME.

Lori Smith, MBA, graduate medical education administrative director, Cleveland Clinic 
Smith received her bachelor’s degree in organizational management and her master’s in business administration (leadership track) from Tiffin University; she is currently working toward her doctorate in education with an emphasis on organizational development. In her role, she oversees all aspects of GME, including institutional and program accreditation, reimbursement, policy, department operations, and HR administration of a large health system. Smith has more than 28 years of progressive GME experience, having worked as both a program coordinator and in GME administration. For her work in the field, Smith was awarded the Caregiver Excellence Award for Innovation in relation to cost repositioning efforts in 2015. She has given numerous local and national presentations, including for the ACGME, AHME, and AAMC.

Anna M. Zulia, M.Ed., graduate medical education program liaison, Cleveland Clinic 
Zulia focuses on the intersection of GME operations, accreditation, and technology while pursuing opportunities to maximize reimbursement return and reduce regulatory agency audit risk. Her broad scope of GME understanding and residency management system expertise is valuable when consulting with training programs within the health system. Zulia previously served as the residency management system manager and drove workflow optimization efforts for user groups. Additionally, she provided training resources for faculty, residents/fellows, and program coordinators. She co-authored multiple poster presentations at AHME and the Group on Resident Affairs national meetings. Zulia holds a Bachelor of Science in Social Work from Ohio State University and a Master of Education from Ohio University.


Page Count: 200 

Dimensions: 8 1/2 X 11 Perfect Bound 
ISBN: 978-1-68308-557-7 

Table of Contents

  • Introduction 
  • Section 1: The Next Accreditation System 
    • History of Allopathic Training 
    • History of Osteopathic Training 
    • Single Graduate Medical Education Accreditation System 
    • Osteopathic Recognition 
    • Data Driven/Importance 
    • Continuous Improvement 
  • Section 2: Graduate Medical Education Community 
    • The Learning and Work Environment 
      • Resident Forum 
      • Salary and Benefits 
      • Time Away 
      • Tools 
      • Quality and Patient Safety Resources and Tools 
      • Service vs. Education 
      • Basic Needs 
      • Supervision 
      • Transitions of Care 
      • Clinical Experience and Education, aka Duty Hours 
      • Professionalism 
    • Roles and Responsibilities 
    • Program Coordinator Importance 
  • Section 3: Institutional Accreditation 
    • Graduate Medical Education Council Oversight/Institutional Requirements 
      • Introduction 
      • Structure of Educational Oversight 
      • Oversight of Rotations at Participating Sites 
      • Graduate Medical Education Council Structure and Membership 
      • Role of the Graduate Medical Education Council Committee Coordinator 
      • Graduate Medical Education Council Subcommittees 
      • Annual Institutional Review 
      • Graduate Medical Education Council Special Review 
    • Clinical Learning Environment Review 
      • Overview of Clinical Learning Environment Review 
      • Institutional Communication and Engagement 
      • Graduate Medical Education Office—Planning for Your Clinical Learning Environment Review Visit 
      • Clinical Learning Environment Review—The Phone Call 
      • During the Clinical Learning Environment Review Visit 
      • After the Clinical Learning Environment Review Visit 
      • Analyzing the Clinical Learning Environment Review Report 
      • Using the Clinical Learning Environment Review Report for Continuous Improvement 
      • Developing Metrics to Monitor Progress 
      • Pursuing Excellence in Clinical Learning Environments 
  • Section 4: Program Accreditation 
    • Changes in the Common Program Requirements 
      • Requirement Recategorization 
      • TCGNAS Specialty-Specific Program Requirements 
        • Internal Medicine Subspecialty Education Coordinators 
      • Annual Notification Letter 
      • Site Visits 
      • Self-Study and 10-Year Accreditation Site Visit 
    • Compliance 
      • Accreditation Data System 
        • The Program’s Perspective 
        • The Annual Update 
        • The Sponsoring Institution’s Perspective 
        • ACGME Data Resource Book 
      • Case Logs 
        • Recording and Monitoring 
        • Reporting 
      • Clinical Competency Committee 
        • Written Description 
    • Composition of the Clinical Competency Committee 
    • Meetings 
    • Responsibilities 
      • Review Process 
      • Summative Evaluation 
    • Milestones 
      • Introduction 
      • Milestone Package 
      • What’s Different About Milestone Evaluations? 
      • Leveraging Your Residency Management System 
      • What Happens to the Data? 
    • Surveys 
      • ACGME Annual Surveys 
      • Institution-Based Annual Surveys 
      • Resident Forum Annual Surveys 
      • Quality and Patient Safety Surveys 
    • Program Evaluation Committee 
    • Annual Program Evaluation 
      • Resident Performance (V.C.2.a) 
      • Faculty Development (V.C.2.b) 
      • Graduate Performance (V.C.2.c) 
      • Program Quality (V.C.2.d) (1–2) 
      • Progress on the Previous Year’s Action Plan(s) (V.C.2.e) 
  • Section 5: Conclusion 
  • Appendix 
    • Program Coordinator Tasks 
    • GMEC Attendance Tracking Template 
    • GMEC Agenda Template 
    • GMEC Minutes Template 
    • GMEC Resolution 
    • CLER Visit—Task Listing (Prior to Call) 
    • CLER Visit—Task Listing (After the Call) 
    • CLER Visit—Task Listing (After the Visit) 
    • CLER Visit—PD Meeting Attendee Tracking 
    • CLER Visit—QPS Meeting Attendee Tracking 
    • CLER Final Agenda 
    • CLER Comparing Academic Year vs. Academic Year and National Data