By Lynne Meyer, PhD, MPH
August 2014
What is CLER?
 CLER Site Visits are required by the ACGME every 18
months (similar style to JCAHO)
 Focuses on the learning environment, not just the
residency program
 Focuses on Patient Safety, Quality, Health Care
Disparities, and more
 Effective July 2013 for all ACGME-accredited programs
The Big Picture: Resident, Faculty,
Program and Institution Reviews
Review of Program
Personnel
Review of Program
Institutional Review
Every 6 months: SemiAnnual Review of
Residents
Once a year: Review of
Program by Program
Evaluation Committee
(PEC)
Every 18 Months:
Clinical Learning
Environment Review
(CLER)
Once a year: Review of
Faculty
Once a Year: Review of
Program by ACGME
Review Committee
PRN: Progress Reports,
Focused or Full Site Visits
as determined by Review
Committee based on data
review
Every 10 Years: Self-Study
Visit
CLER Site Visit Components:
Meetings and Walk Arounds
 Meet with:
 Senior Leadership
 Quality and Safety Leadership
 Residents/Fellows
 Core Faculty
 Program Directors
 Walk Arounds to check on 6 focus areas for CLER
Who’s involved?
 EVERYONE
 Program Directors
 Faculty
 Resident/Fellows
 Hospital Administration
 Nurses/Technicians/Pharmacists, etc.
CLER Site Visit Information
 SHORT NOTICE: 10 days to 3 week notice
 Visits will last 2-5 days (probably 2-3 days)
 Our 1st CLER visit will only be used for feedback and
baseline data
CLER’s 6 Focus Areas
 Patient Safety
 Quality Improvement (including Health Disparities)
 Transitions in Care
 Duty Hours, Fatigue Management & Mitigation
 Supervision
 Professionalism
CLER Focus Areas
Integration of residents
into institution’s Patient
Safety programs, and
demonstration of
impact
 including opportunities for
residents to report errors,
unsafe conditions, and near
misses, and to participate
in inter-professional teams
to promote and enhance
safe care
CLER Focus Areas
Integration of residents into institution’s Quality
Improvement programs and efforts to reduce
Disparities in Health Care Delivery, and
demonstration of impact
 including how sponsoring institutions engage residents
in the use of data to improve systems of care, reduce
health care disparities and improve patient outcomes
Patient Handoffs: A Typical Day on
the Wards
 http://www.youtube.com/watch?v=JzCdoQEYHkY
 What processes do you use to standardize and improve
your handoffs
CLER Focus Area: Hand-offs
Oversight of
Transitions in Care
 including how
sponsoring
institutions
demonstrate
effective
standardization and
oversight of
transitions of care
 We will be
implementing a
standardized
process
CLER Focus Areas
Oversight of Duty Hours Policy, Fatigue
Management and Mitigation including how
sponsoring institutions:
 (i) demonstrate effective and meaningful oversight of
duty hours across all residency programs institutionwide;
 (ii) design systems and provide settings that facilitate
fatigue management and mitigation; and
 (iii) provide effective education of faculty members and
residents in sleep, fatigue recognition, and fatigue
mitigation.
CLER Focus Areas
Establishment, implementation, and oversight of
Supervision policies
 including how sponsoring institutions maintain and oversee
policies of supervision concordant with ACGME
requirements in an environment at both the institutional
and program level that assures the absence of retribution
Excerpt from Resident Survey
CLER Focus Areas
Education and monitoring of Professionalism
with regard to how sponsoring institutions educate for
professionalism, monitor behavior on the part of residents and
faculty and respond to issues concerning:
 (i) accurate reporting of program information;
 (ii) integrity in fulfilling educational and professional
responsibilities; and
 (iii) veracity in scholarly pursuits
Excerpt from ADS Annual Update
How would you answer these?
 What areas have the hospital identified as opportunities for
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improvement?
What types of patient safety activities are you involved in?
What is an RCA?
Do you know how your individual QI and patient safety projects relate
to the hospital’s overall plan?
Have you reported Medical Errors, Unsafe Conditions, or Near Misses?
What is the process for reporting Medical Errors, Unsafe Conditions, or
Near Misses?
How effective is the dialogue during hand-offs?
How effective are educational efforts around sleep and recognizing and
preventing fatigue?
Is the level of supervision you experience adequate for your level of
training?
SV Components: Walk Arounds
 Possible Areas of Focus:
 Primary focus on hand-off for change of duty
 Check for variability in process and oversight of resident
hand-offs
 Look for examples of both under and over supervision
 See if knowledge of need for direct supervision appears
to be limited to GME faculty
 Look for consistent vs. variable evidence of effective
management strategies for duty hours and fatigue
management
SV Components: Walk Arounds
 Walk arounds of patient floors, OR and clinics: need
experienced chief or senior residents (PGY3 or higher)
 Random interviews of staff (e.g. nurses, techs, pharmacist):
 Talk with nurses
 Talk with other residents and physicians on units
 Possible patient contact
 May ask people encountered about their perspective of
residents related to the six focus topics
 The CLER team will want to observe a handoff without
supervision
 May return in the evening
Accessing the PSR….
 https://my.portal.shands.ufl.edu/portal/page/portal/SHCE
MPAUTH
 After you log in, an express report is available
Examples of Medical Errors
 Failure to employ indicated tests
 Error in the dose or method of using a drug
 Failure to provide prophylactic treatment
 Failure of communication
 Equipment failure
Why Report Near Misses
 Not wait for harm to occur
 Trigger improvements in weak spots in the care
process
 Alert others for possible vulnerabilities and training
gaps
 Contribute to planning, recovery testing, harm
mitigation strategies following events that do result in
harm
PDQ List
 https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/Lists/PD
Q%20List/AllItems.aspx
CLER and our Focus on Patient
Safety and Quality
 We need to role model and teach these
concepts to our fellows, residents and
medical students so they become a way
of life.
Documentation of CLER
We must document what we teach, what we learn and outcomes for:
 Patient Safety
 Quality Improvement -- if on QI/PS project – document in New
Innovations
 Transitions in Care – used a standardized process such as SBAR or IPASS
 Duty Hours, Fatigue Management & Mitigation
 Supervision
 Professionalism
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Do you use the PSR when indicated?
Do you review the goals and objectives with your learners?
Do you provide your learners with feedback? (formative)
Do you return your evaluations on time with meaningful
data/comments? (summative)
Resources
GME Housestaff: Housestaff Patient Safety and Quality Improvement
Committee – Lee Titsworth, MD, Chair
http://gme.med.ufl.edu/policy-procedures/patient-safety/
https://ufhealth.org/quality-and-patient-safety/welcome
UF Health: Sebastian Ferrero Office of Clinical Quality and Patient
Safety
https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/SitePages/Ho
me.aspx
Resources
ACGME’s CLER Program http://acgme.org/acgmeweb/
Sites with Curriculum and Cases to work
through
AHRQ Patient Safety Network http://psnet.ahrq.gov/
AHRQ webM&M http://www.webmm.ahrq.gov/
VA National Center for Patient Safety
http://www.patientsafety.va.gov/professionals/training/curriculum.asp
Questions?
 lynnemeyer@ufl.edu
352-594-6226