Accreditation Council for
Graduate Medical Education
Clinical Learning Environment Review (CLER)
February 4-6, 2014, Interim LSU Hospital
Background
As a component of its next accreditation system, the ACGME has established the CLER program to assess
the graduate medical education (GME) learning environment of each sponsoring institution and its
participating sites. Each sponsoring institution will be visited every 18 months.
The CLER visit will review institutional activities in the areas of safety, quality improvement, transitions
in care, supervision, duty hours oversight, fatigue management/mitigation, and professional
responsibilities.
 Integration of residents into patient safety programs
 Integration of residents into QI and efforts to reduce disparities
 Establishment and implementation of supervision policies
 Oversight of transitions of care
 Oversight of duty hours
Central CLER Questions
1. Who and what form the infrastructure of a Sponsoring Institution’s (SI) clinical
learning environment?
2. How integrated is the GME leadership and faculty within the SI’s current
clinical learning environment infrastructure?
3. How engaged are the residents and fellows in using the SI’s current clinical
learning environment infrastructure?
4. How does the SI determine the success of its efforts to integrate GME into the
quality infrastructure?
5. What areas have the Sponsoring Institution identified as opportunities for
improvement?
This first visit
focuses on
questions 1-3.
Questions 4-5
will be used in
subsequent
visits
Visit Framework
1. Initial meeting and Exit meeting with senior leadership group (CEO, CMO, CNO, DIO)
2. Series of walk around visits in the hospital – senior resident serves as tour escort
3. Separate group meetings with residency program directors, core faculty, and peerselected residents
4. Meetings with hospital’s chief quality officer and chief safety officer

In this initial visit is, the findings will not be held against the institution unless an egregious
violation is identified. The ACGME’s example of an egregious violation is a PGY-1 starting a
laparotomy in the OR without a faculty member present.
“How to I prepare my faculty and residents?”
Answer all questions honestly and completely. We want an accurate picture of how we’re doing.
Examples of Questions They May Ask:
Patient Safety
How do residents report errors or near misses?
Does the hospital provide a safe, non-punitive environment for reporting errors, near misses and unsafe
conditions? (asked of residents, faculty, program directors, administration and nursing)
Is reporting consistent across specialties?
Have you ever witnessed an adverse event, near miss, or unsafe condition?
Did you report it? How did you report it?
To the faculty: How do residents report adverse events, near misses, or unsafe conditions?
What happens to those reports?
Are residents given feedback once they report an error or near miss?
Are residents involved in root cause analyses? If so, how?
What happens to events discussed during M&M conferences? Is the information transferred to a
central repository? Do these conferences lead to formal investigations or system analyses?
Does your program adequately integrate the hospital’s patient safety priorities, policies, and procedures
into the curriculum?
What are the hospital’s safety priorities in the area of patient safety?
Quality Improvement
What are the hospital goals for quality? Are they aligned with national priorities?
Are residents/faculty/program directors aware of these goals?
How are residents involved in attainment of those goals?
Are residents involved in strategic planning or monitoring of the attainment of these goals?
How do you train your residents and fellows in quality improvement and patient safety?
Is there a standard curriculum?
Do your residents feel “ownership” of hospital QI processes?
Do your residents have access to organized systems for collecting and analyzing data for the purposes of
quality improvement?
Have you participated in a quality improvement project?
Does the organization make efforts to address healthcare disparities?
How are healthcare disparities measured?
Transitions of Care
Where does the hospital believe there are issues related to transitions of care?
Are residents/faculty aware of these?
How do residents perform transitions of care (handoffs)?
Do they use a form? A computerized template?
Are handoffs monitored? If so, by whom?
Does each program utilize the same system?
Supervision
Do you feel that you are adequately supervised?
Do you feel free to ask for help when you are unsure?
Is it easy to reach out to a supervisor at night?
Do your supervision policies allow for advancement towards independence?
Have you ever been placed in a situation where there was inadequate supervision?
Do you have an objective way of knowing which procedures a particular resident is allowed to perform?
Do you (resident) have an objective way of knowing whether another resident is able to perform a
specific procedure?
How would a nurse know if you are credentialed to do a procedure independently?
To nurses: How would you identify a resident’s required level of supervision?
Duty Hours, Fatigue Management and Mitigation
What do you think of duty hour restrictions?
If you were fatigued while on the job, what would you do?
If you felt that you couldn’t drive yourself home, due to fatigue, what would you do?
Are there facilities available for you to nap if needed?
Is the culture of your hospital responsive to identifying and managing fatigue?
How were you educated about fatigue?
Professionalism
Do you receive education about professionalism?
Does your hospital provide a supportive, non-punitive environment for bringing forward concerns
regarding honesty in reporting?
Have you ever felt pressured to compromise your integrity to satisfy an authority figure?
Scenario: An attending mistreats a colleague. How would you advise the colleague? What if the
colleague was uncomfortable going through the GME chain of command?
Have you ever documented a history or physical finding that you didn’t personally elicit?
Do you have access to unpublished board review questions?
Do you accurately report your duty hours?