Clinical Learning Environment Review

EMPLOYERS ROLE IN CYBER SECURITY: CLINICAL LEARNING ENVIRONMENT REVIEW (CLER): SETTING A PATHWAY TO

EXCELLENCE FOR GRADUATE MEDICAL EDUCATION

CREATING A COLLABORATIVE EFFORT WITH GME DEPARTMENTS TO ASSURE SUCCESS

By Barbara Youngberg

As many working in the Academic

Medical Centers environment know, an

important component of their mission is

to prepare future providers to use best

practices to optimize care for their

patients. The month of July marks the

beginning of every new graduate

physician’s career of caring for patients

and contributing to keeping the

environment in which they work safe by

practicing mindfulness and fostering a

culture of respect. In a press release on

January 27, 2014 the American College of Graduate

Medical Education (ACGME) instituted the Clinical

Learning Environment Review (CLER) program as part

of its accreditation program to promote this culture.i

The press release stated:

“This effort creates the framework to reshape the

clinical environments in which tomorrow’s doctors learn

to deliver quality patient care and respond to rapid

developments in health care delivery. Summarized in a

paper published in the January 27, 2014 online edition

of the New England Journal of Medicine and

announced to health care leaders at a policy forum in

Washington, DC, the ACGME’s new guidance called

the Clinical Learning Environment Review (CLER)

Pathways to Excellence represents a roadmap for the

approximately 700 accredited institutions and their

9,000 residency and fellowship programs across the

country to improve resident and fellow physicians’ skills

in addressing issues of patient safety and health care

quality as an essential component of modern medical

practice. The ACGME will also use the Pathways to

Excellence framework as the foundation for issuing

periodic reports on the performance of graduate

medical education (GME) programs in preparing the

physician workforce in patient safety

and quality improvement.” ii

Launched in conjunction with the

transition to the Next Accreditation

System (NAS), the Clinical Learning

Environment Review (CLER) program is

an ongoing initiative to assess the

learning environment at each

accredited teaching institution. As a

critical component of this initiative, the

CLER Pathways to Excellence document

is intended as a guide to improve physician education

in the patient care environments in which residents and

fellows learn, and as such:

Incorporates findings from more than

100 site visits conducted in 2013 and

input from national focus groups

involving designated institutional officials

(DIOs) and chief medical officers

(CMOs) from GME teaching hospitals,

medical centers and clinics from across

the country

Defines the expectations for an optimal

clinical learning environment to deliver

high quality and safe patient care while

seeking to educate our nation’s new

physicians

Lays out the pathways for teaching

hospitals, medical centers and clinics to

improve resident and fellow physician

engagement in six core areas: patient

safety; health care quality; care

transitions; supervision; duty hours;

fatigue management and mitigation;

and professionalism

Financial Services July 2015

Launched in

conjunction with the

transition to the

Next Accreditation

System (NAS), the

CLER program is an

ongoing initiative to

assess the learning

environment at

each accredited

teaching institution.

INATIONS EXAM

July 2015

A Beecher Carlson Publication

Examining the industry market trends that matter most to you

Provides tools for institutions to monitor

their progress over time and prioritize

areas for future improvementsiii

Risk managers and patient safety professionals certainly

are cognizant of the unique challenges they face

every July with newly graduated health care

professionals. They often struggle with providing these

recent graduates the information necessary in orienting

them to important risk management and patient safety

topics due to the many competing demands placed

on the incoming resident, as well as the limits on how

much a new physician can absorb without

experiencing information overload and anxiety.

Familiarizing the risk manager and patient safety

professional with the pathways and the expectations of

the CLER program might enable them to design more

focused educational information programs and tools in

conjunction with the office of GME and the attending

physicians supervising new trainees to assure the

highest quality physician workforce.

WHY DID ACGME DEVELOP THE CLER PROGRAM?

The physician workforce is one of the key levers to

improving healthcare. A survey of hospital leaders

conducted by the American Hospital Association

(AHA) found that newly trained physicians were often

deficient in the areas of communication, the use of

systems-based practices, and inter-professional

teamwork. The survey highlighted the need to better

educate U.S. physicians, residents and fellows to foster

improvements in quality.iv Of course many years prior,

the Institute of Medicine (IOM) issued a number of

reports which highlighted the systemic issues that

contributed to the alarming number of preventable

medical errors and challenged providers and provider

organizations to more effectively address the most

common system problems. These systems issues have

been the focus of much of the work done by risk

managers and patient-safety professionals. Many of

these systemic issues are addressed in the pathways

created in the CLER program.

The CLER Pathways to Excellence program was

developed by the ACGME’s CLER Evaluation

Committee, a group that provides oversight and

guidance on all aspects of CLER program

development. The CLER Evaluation Committee

represents a broad range of perspectives. Members

were selected based in their national and international

expertise in areas of patient safety, healthcare quality,

fatigue mitigation, hospital administration, graduate

medical education and patient advocacy. The

development of the CLER Pathways to Excellence was

formed by the expertise of the committee members,

selected published literature, input from the CLER field

staff (based on over a hundred site visits) and input

from focus groups of chief medical officers and others

from GME teaching institutions across the country. v

The program will be based on principles of continuous

quality improvement and will evolve over time to

reflect what is learned from the site visits, as well as

input from GME leadership, the executive leadership of

ACGME, accredited teaching hospitals, other clinical

sites and the community.

HOW DOES THE CLER PROGRAM WORK?

Site visits will be conducted by the CLER

Evaluation Committee during which residency

sites will be evaluated against the specific

pathways. The purpose of the site visit is to

evaluate, encourage and promote improvements

to the clinical learning environment. The CLER

program provides the sites visited with three types

of formative feedback: an oral report at the end

of the site visit, a written narrative report

summarizing the site visitor’s observations and, in

the future, a report that will provide national

aggregated and de-identified data displayed

along a continuum of progress towards achieving

optimal resident and fellow engagement in the six

focus areas. vi

During the site visit, members of the CLER site visit

team meet with the senior leadership of the

organization and with those individuals responsible

for patient safety, healthcare quality and

informatics, and GME. In addition, they meet with

residents and fellows along with faculty members

and program directors. The CLER team also visits

units and clinics where care is provided in order to

assess the culture of learning in place in the

organization.vii At the conclusion of the site visit

the CLER team will meet with the organization’s

team to de-brief and share preliminary findings

and impressions.

While the CLER site visit program is part of the NAS,

it is separate and distinct from nearly all

accreditation activities. There are two essential

elements that connect CLER with the rest of the

accreditation process. The first is that each

sponsoring institution is required to periodically

undergo a CLER visit (currently targeted to occur

every 18-24 months). The second is that the Chief

Executive Officer and the leader of GME

(specifically the Designated Institution Official

(DIO)) for the clinical site must attend both the

opening and closing sessions of the CLER visit.viii

THE RISK MANAGER’S ROLE IN CLER

ACCREDITATION

As is obvious, the risk manager, patient safety

officer and quality improvement staff can assist

their organization in achieving success in the CLER

Pathway to Excellence program. To avoid

redundancy of effort and to assure the best

resources in the organization are brought to bear,

the 40 page document developed by ACGME

should be reviewed by all staff who will play a role

in CLER accreditation

(https://www.acgme.org/acgmeweb/Portals/0/P

DFs/CLER/CLER_Brochure.pdf). Although the

various pathways which form the basis of the

assessment are found in the appendix of this

article, the ACGME document describes in

greater detail the specific properties that would

lead the assessment team to conclude the

organization was on the pathway to excellence.

As would be suspected, many of these properties

are organizational attributes which risk

management and patient safety professionals

already know are present in a robust culture of

safety.

Meet with GME director or DIO to discuss

the role which the risk management,

patient safety and QI departments can

play in helping GME program meet CLER

goals. Identify areas of existing expertise.

Encourage reporting of actual and near

miss events by residents and fellows. You

may do this by creating easy “how to”

pocket card detailing how to report an

event and what will happen once the

event is reported. You may wish to create

some campaigns which focus on the

reporting and analysis of specific event

types that might be most relevant to

residents and fellows (these might include

events occurring due to failed hand-off

protocols, events that are related to fatigue

or burnout or events where a hierarchical

structure may have contributed to failed

communication).

Verify that the event reporting system has a

data field for easily identifying events

where residents and fellows are involved

and when systemic factors include those

commonly cited by ACGME

(communication failure, handoff failure,

fatigue, supervision etc.).

Prepare an annual survey (to be offered in

June) to measure impact of efforts to

support residents and fellows in support of

patient safety.

Invite residents and fellows to sit on risk

management, patient safety and QI

committees to review the events reported

and to identify solutions. Include them in

the root cause analysis or FMEA’s where

residents and fellows are involved. Provide

them with clinical data used to evaluate

trends and identify opportunities for

improvement. Residents and fellows will

need to be convinced early on that the

time they spend reporting events will make

a difference in the care their patients

receive. Early on, students struggle to

balance all of the competing priorities and

pressures of being a new physician, and it

will be important to demonstrate the value

of reporting by providing timely feedback.

If the organization has an intranet, the CLER

program should be described and the

individual roles that residents and fellows

play to assure the program’s success should

also be described. In addition, brief

articles should be posted that relate to

each of the CLER pathways especially

those that relate to educational principles

and practices of patient safety such as

communication, culture, fatigue, hand-offs,

supervision, managing disparities, proactive

risk management practices that support

patient safety and use of data to drive

improvement.

Involve residents and fellows in

disclosure training that is offered to all

medical staff. Use simulation techniques if

possible.

Identify tools and templates that have

been designed by the organization to

facilitate and standardize the hand-off

process. Make certain residents and fellows

are aware of these tools.

Identify residents and fellows who can be

designated champions and mentors. They

can assist in promoting these practices

among their peers.

ABOUT THE AUTHOR

Barbara J. Youngberg has joined Beecher Carlson as a

Consultant to the national healthcare practice. She has

more than 25 years of experience in the healthcare

industry focused on legal and regulatory issues, risk

management and patient safety concerns and internal

operations in academic medical centers and complex

teaching hospitals. Barbara currently works as a Visiting

Professor and Director Faculty of the On Line Programs

at the Beazley Institute for Health Law and Policy at the

Loyola University College of Law in Chicago. Contact

Barbara Youngberg at

[email protected].

Disclaimer

This article is intended for informational purposes only. It is not a

guarantee of coverage and should not be used as a substitute for an

individualized assessment of one’s need for insurance or alternative

risk services. Nor should it be relied upon as legal advice, which

should only be rendered by a competent attorney familiar with the

facts and circumstances of a particular matter.

Copyright Beecher Carlson Insurance Services, LLC. All Rights

Reserved.

i

http://www.acgme.org/acgmeweb/portals/0/pdf

s/cler/acgmeclernewsrelease.pdf (accessed June

14, 2015)

ii



14, 2015)

iii



14, 2015)

iv Combes.JR,Arespacochaga.E , American Hospital Association Physician Leadership Forum Lifelong

Learning:Physician Competency Development ,Chicago,IL:American Hospital Association;June.2012 www.ahaphysicianforum.org/files/pdf/physician-competency-development .pdf (accessed 6/14/2015)

(Accessed.February.9,.2013)

v

https://www.acgme.org/acgmeweb/Portals/0/PD

Fs/CLER/CLER_Brochure.pdf (accessed 6/11/2015) vi


Fs/CLER/CLER_Brochure.pdf (accessed 6/11/2015) vii


Fs/CLER/CLER_Brochure.pdf (accessed June 14,

2015)

viii


Fs/CLER/CLER_Brochure.pdf

http://www.acgme.org/acgmeweb/portals/0/pdfs/cler/acgmeclernewsrelease.pdf






https://www.acgme.org/acgmeweb/Portals/0/PDFs/CLER/CLER_Brochure.pdf








APPENDIX

CLER PATHWAYS TO EXCELLENCE viii

PATIENT SAFETY PATHWAYS

#1 – Reporting of adverse events, close calls (near misses)

#2 - Education on patient safety

#3 - Culture of safety

#4 – Resident / fellow experience in patient safety investigations and follow-up

#5 – Clinical site monitoring of resident / fellow engagement in patient safety

#6 – Clinical site monitoring of faculty member engagement in patient safety

#7 – Resident / fellow education and experience in disclosure of events

HEALTH CARE QUALITY PATHWAYS

#1 – Education on quality improvement

#2 – Resident / fellow engagement in quality improvement activities

#3 – Residents/ fellows receive data on quality metrics

#4 – Resident/ fellow engagement in planning for quality improvement

#5 – Resident / fellow and faculty member education on reducing health care disparities

#6 – Resident / fellow engagement in clinical site initiatives to address health care disparities

CARE TRANSITIONS PATHWAYS

#1 – Education on care transitions

#2 – Resident / fellow engagement in change of duty hand-offs

#3 – Resident / fellow and faculty member engagement in patient transfers between services and locations

#4 – Faculty member engagement in assessing resident – related patient transitions of care

#5 – Resident / fellow and faculty member engagement in communication between primary and consulting teams.

#6 – Clinical site monitoring of care transitions

SUPERVISION PATHWAYS

#1 – Education on supervision

#2 - Resident / fellow perception of the adequacy of supervision

#3 – Faculty member perception of the adequacy of resident /fellow supervision

#4 - Roles of clinical staff members other than physicians in resident / fellow supervision

#5 – Patients and families, and GME supervision

#6 – Clinical site monitoring of resident / fellow supervision and workload

DUTY HOURS, FATIGUE MANAGEMENT AND MITIGATION PATHWAY

#1 – Culture of honesty in reporting of duty hours

#2 – Resident / fellow and faculty member education on fatigue and burnout

#3 – Resident / fellow engagement in fatigue management and mitigation

#4 – Faculty member engagement in fatigue management and mitigation

#5 – Clinical site monitoring of fatigue and burnout

PROFESSIONALISM (SELECTED TOPICS) PATHWAYS

#1 - Resident / fellow and faculty member education on professionalism

#2 – Resident / fellow attitudes, beliefs, and skills related to professionalism

#3 – Faculty engagement in training on professionalism

#4 – Clinical site monitoring of professionalism

Clinical Learning Environment Review

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