Example CLER questions that may be asked of Residents, Faculty, Nurses, Techs, Faculty, GMEC, CEO, etc.
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Do you know the hospital’s quality goals?
https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/Goals/default.aspx
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Do you know how your individual QI and patient safety projects relate to the hospital’s overall plan?
Do the faculty members? GMEC committee?
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Possible CLER Questions
What is an RCA? – Root Cause Analysis
Who all participates in RCAs? Are they Interdepartmental? Interprofessional (e.g. not just other
physicians, but pharmacists, nurses, techs, biomechanical engineers, etc.)?
Do you work together with residents/fellows on RCAs?
What types of patient safety activities do you participate in with residents and fellows? examples may
include:
 institution-wide efforts to increase resident reporting of errors and near misses (case-based lectures,
hands-on interaction with online reporting system, DIO’s resident challenge to report one PSR/month
on back of Strive for Five badge buddy)
 group participation (Housestaff PS/QI Committee, clinical or hospital-based quality & safety
committees, clinical practice committees, EMR/Health IT committees, patient satisfaction/patient
experience committees )
 Personal performance measures based on a resident’s own panel of patients
 Innovative morbidity and mortality conferences
What is the policy for reporting patient safety events?
Shands Core Policy and Procedure: CP01.030 –
Patient Safety Reports (PSR)/Event Management Process for Patient and Visitor Accidents and Incidents
All patient and visitor incidents occurring on UF Health Shands (Shands) patient care units or work sites,
e.g.
including those apparently minor in nature, shall be reported promptly, but not greater than three business
days from the occurrence of the event. Events shall be reported using the electronic event management
system known as IDinc and reviewed by the Risk Manager, or Risk Manager Designee, within three business
days of the report.
Incidents which appear to meet the definition of Sentinel Events and/or Adverse Incidents shall be
immediately reported by telephone to the Patient Safety Hotline at 352-538-2635 and then entered in IDinc as
a Patient Safety Report.
https://my.portal.shands.ufl.edu/portal/page/portal/DEPT_CONTENT/Policies/CORE/CP01%20%20General%20Administrative/CP01.030_.pdf
https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/Goals/default.aspx
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Example CLER questions that may be asked of Residents, Faculty, Nurses, Techs, Faculty, GMEC, CEO, etc.
Do you know how your individual QI and patient safety projects relate to the hospital’s identified
opportunities for improvement?
https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/QualityAnalytics/Shared%20Documents/
Forms/AllItems.aspx
Core Measures 2014 – Inpatient: Acute Mycoardial Infarction; Heart Failure; Pneumonia; Surgical
Care Improvement Project; Stroke; Inpatient Psychiatric Services; VTE; Perinatal Care;
Immunization; Emergency Department
Core Measures 2014 – Outpatient: AMI/Chest Pain; Surgical Care Improvement Project;
Emergency Department; Stroke; Pain Management;
Refer to for further Information:
https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/QualityAnalytics/Shared%20Documents/F
orms/AllItems.aspx
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What areas have the Sponsoring Institution identified as opportunities for improvement?
Goals:
https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/Goals/default.aspx
Core Measures:
https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/QualityAnalytics/Shared%20Documents/
Forms/AllItems.aspx
Expand “Category: Core Measures” and view “Core Measures 2014” and “Core Measure Graphs
11202014” documents
To Residents: Have you reported Medical Errors, Unsafe Conditions, or Near Misses? How do you
report these?
 Shands portal: https://my.portal.shands.ufl.edu/portal/page/portal/SHCEMPAUTH
 Click on “Patient Safety Report – UF Health Shands”  Select Report an Event
 After you log in, an express report is available
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Do our residents file reports of safety concerns—or do they leave it to the nursing staff?
Is there anything that would prohibit the residents from reporting a safety concern?
If a resident reports a concern, does he/she get feedback about what action was taken?
How would you describe the “Just Culture” in your institution?
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What is a “Just Culture”? A Fair and Just Culture is one that learns and improves by openly identifying and
examining its own weaknesses. Organizations with a Just Culture are as willing to expose areas of weakness
as they are to display areas of excellence. Of critical importance is that caregivers feel that they are supported
and safe when voicing concerns
How effective is the dialogue during hand-offs?
Residents/Fellows must have skills to “analyze and improve the quality of their practice.” How are we
doing on providing the following example measures?
 Proportion of patients receiving immunizations according to schedule
 Proportion of patients receiving routine screenings — such as colonoscopy,
mammography, or HbA1c — according to guidelines
 Proportion of patients from the last six months with asthma who have an active asthma
action plan
 Types of drugs prescribed and their costs
 Complication rates following procedures
Timely feedback of these data with some benchmarking against other providers within the
same clinic or within the same institution can help trainees see how their work fits into the
larger picture. Sharing results across the clinical setting can motivate the group and
facilitate group learning.
To residents/fellows…..is the level of supervision you experience adequate for your level of training?
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What are example goals of reducing health care disparities?
 Improve data collection and measurement of health data by race, ethnicity, sex, primary language,
and disability status
 Ensure access to quality, culturally-competent care for vulnerable populations by improving the
cultural competency and diversity of the health care workforce and addressing disparities in access
to care
 Achieve health equity
Do we have any service areas where unprofessional behavior has been ongoing and unresolved?
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Example CLER questions that may be asked of Residents, Faculty, Nurses, Techs, Faculty, GMEC, CEO, etc.
What organizational structures and administrative and clinical processes does the hospital have
in place to support GME learning in each of the six focus areas (PS, QI, Transitions in Care,
Professionalism, Duty Hours and Fatigue Management, Supervision)?
For example, policies are in Place – both institution wide and program specific. Institution wide
policies are located here:
http://gme.med.ufl.edu/policy-procedures/gme-policies-and-procedures/
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How does the hospital determine the success of its efforts to integrate GME into the quality
infrastructure? What are the outcome measures?
How integrated is the GME leadership and faculty within the sponsoring institution’s (SI’s) current
clinical learning environment infrastructure?
How engaged are the residents and fellows in using the SI’s current clinical learning environment
infrastructure?
Who and what form the infrastructure of a Sponsoring Institution’s clinical learning environment?
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How well do faculty and residents know the policies related to supervision? Transitions to care?
Institution wide policies are located here:
http://gme.med.ufl.edu/policy-procedures/gme-policies-and-procedures/
Program specific policies are located on New Innovations: Program (white bar): Policies
What is the policy for handoffs?
Institution wide policies are located here:
http://gme.med.ufl.edu/policy-procedures/gme-policies-and-procedures/
Program specific policies are located on New Innovations: Program (white bar): Policies
What type of handoff model is used? (E.g. SBAR, I-PASS, SIGNOUT, etc.)
The GMEC is in the process of recommending one standardized handoff process for everyone: I-PASS
http://www.ipasshandoffstudy.com/ and
http://pediatrics.aappublications.org/content/129/2/201/F1.expansion.html
I-Illness severity
P-Patient Summary
A-Action List
S-Situation and Awareness and Contingency Planning
S-Synthesis by Receiver
What about the handoffs between physician and nurses?
Does everyone identify themselves and their role to the patients?
If the fatigue management policy for residents and fellows recommends strategic napping, do
residents ever take strategic naps?
Policy: http://gme.med.ufl.edu/files/2012/07/Housestaff-Faculty-Fatigue.pdf –
excerpt: “ The education program must specifically also address fatigue mitigation techniques
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including but not limited to strategic napping and good sleep hygiene.”
What happens when a resident is too tired to function during a shift, or is too tired to safely leave
at the end of a shift?
How effective are educational efforts around sleep and recognizing and preventing fatigue?
Examples may include:
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 All faculty, fellows and residents are educated using the SAFER module (Sleep Alertness and Fatigue
Education in Residency) – link is found on New Innovations home page
 Residents meet as a class with a class advisor on a regular basis to discuss a variety of topics, including
maintaining balance and identifying areas both inside and outside the program that may be leading to
disruption of balance.
 A conference or group discussion on the topic of burn out and encourages attendance at other Health
Science Center talks on related subjects.
 Using a sleep tips guide
 Back-up systems can be used if residents are not fit for duty due to fatigue (and it has been used for this
purpose.)
 Residents are regularly encouraged to maintain a healthy work-life balance during all rotations (even
those that do not include night work).
Do you use/participate in checklists, time-outs or step backs, briefings, debriefings, etc.?
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