Making CLER “clear”
Preparing for the
Clinical Learning Environment Review
What is CLER?
“The Clinical Learning Environment
Review (CLER) is a mechanism by which
the ACGME assesses a Sponsoring
Institution (SI) to evaluate its
commitment to developing a culture of
quality, patient safety, and
performance improvement for both
resident education and patient care.”
CLER Goals
 Support national efforts addressing patient safety, quality
improvement, and reduction in health care disparities.
 Monitor Sponsoring Institution maintenance of a clinical learning
environment that promotes the six goals.
 Emphasizes the responsibility of the SI for the quality and safety
of the environment for learning and patient care.
 Increase resident knowledge of and participation in safety
activities and quality improvement.
 Intent to improve physician integration into quality and safety
goals after graduation.
CLER Focus Areas
Supervision
Healthcare Quality
Patient Safety
Professionalism
Healthcare
Disparities
Duty Hours
Fatigue
Management
Transitions of Care
CLER: Five Key Questions
1.
Who and what form was the hospital/medical center’s
infrastructure designed to address the six focus areas?
2.
How integrated is the GME leadership and faculty in
hospital/medical center efforts across the six focus areas?
3.
How engaged are the residents and fellows?
4.
How does the hospital/medical center determine the success of its
efforts to integrate GME into the six focus areas?
5.
What are the areas the hospital/medical center has identified for
improvement?
Who IS the SI?
Who will participate in CLER?
 Phase 1 focused on
“large” program SIs
(about 290 institutions)
 Now moving on to
Phase 2: “small”
program SI: 2 or fewer
core programs, with or
without “subs” (about
450 institutions)
Who IS the SI?
Who will participate in CLER?
 Hospital-sponsored program: the hospital; possibly the
clinic
 Clinic-sponsored (FQHC) program: the clinic, and likely
the hospital as well
 More than one hospital: either possible, but the most
likely is the one where the most rotations are done
 Non-clinical sponsor: the sponsor will need to be
involved, but the clinic and/or hospital will be reviewed
CLER Site Visit Process: Materials
 Intentional short notice (allowance for need to find
other times)
 Limited advance materials to prepare
 Organizational charts
 Policies: Supervision, Duty hour, Care transitions
 Patient safety and Quality protocols/strategies
 Quality & Safety Committee membership rosters
(identifying resident members)
CLER Site Visit Process
 1 or 2 CLER site visitors
 Three methods of obtaining information:
 Interviews of residents, faculty, and program directors using Audience
Response System
 Interviews with SI leadership, and Patient Safety and Quality officers
 “Walk rounds”
 Oral report to leadership at end of visit
 Written report to follow
 Optional program response to report
CLER Site Visit Process: People
 Health-system Leadership: “C-suite” CEO, COO, CMO,
CNO, DIO
 Patient Safety/Quality Officers
 Residency/fellowship program personnel (separately by
group):
Program Directors
Core faculty
Resident representatives
CLER Site Visit Process: People
 Hospital walk-
arounds led by
residents
 Interview hospital
staff
 Observe patient
hand-offs
Senior
Leadershi
p
Meeting
Program
Director
Meeting
Faculty
Member
Meeting
Safety
and
Quality
Leadershi
p
Meeting
Resident
Meeting
CLER Outcomes
 Intended to provide:
 “Aha’s!” Experiences that inform learning
 A progressive set of activities for higher performance in
organizational engagement in GME
 Not intended to provide:
 “Gotcha’s”
 New stealth accreditation requirements
CLER Outcome Examples
 Patient safety:
 ACGME: resident respondents: 67% aware of safety
incident; only 46% reported an incident.
 WWAMI “mock” visits: hospital patient safety systems
highly variable, but many quite robust; residents with only
limited engagement.
 “Aha’s”:
 All institutions have this as one of their highest priorities,
and voiced high level of enthusiasm for engaging more
with residents and faculty.
 Residents enthusiastic when included.
CLER Outcome Examples
 Quality in WWAMI:
 Education on quality improvement
 All institutions had systems, but neither residents nor faculty are regularly
receiving reports.
 Residents not aware of Core Measures or hospital QI priorities.
 Resident engagement in QI activities
 All residents working on quality-oriented projects.
 Residents receive data on quality metrics
 Not consistently occurring.
 Neither meaningful or usable.
 IT personnel struggling to keep up.
CLER Outcome Examples
 Quality in WWAMI:
 Resident engagement in planning for QI
 All institutions voiced strong support for including residents in QI initiatives.
 Few residents currently involved.
 Education on reducing health disparities
 Limited in scope.
 Stronger in FQHC-based programs.
 Resident engagement in initiatives to address health
disparities
 ACGME: almost entirely related to use of interpreters.
 WWAMI: again stronger in FQHC-based programs.
CLER Outcome Examples
 Supervision:
 ACGME: resident respondents: 21% perceived an incident
of inadequate supervision. SI leadership: 43% reported
events related to inadequate supervision, most common
on nights/weekends.
 WWAMI “mock” visits: more positive results in our
programs.
 “Aha’s”: nursing staff “empowerment” to ask questions
and use chain of command when deemed important to
patient safety.
CLER Outcome Examples
 Fatigue management (duty hours):
 ACGME: resident respondents: 32% would “power
through” 2 hours of shift even when “maximally tired”;
underuse of mitigating plans.
 WWAMI “mock” visits: almost full compliance of programs
with duty hours.
 “Aha’s”: culture of “checking in” near ends of shifts.
CLER Outcome Examples
 Professionalism:
 ACGME: resident respondents: 15% compromised their
integrity to satisfy an authority figure. SI leadership: 63%
reported a professionalism issue in past year. Walk
rounds: 75% reported incident of disruptive or
disrespectful behavior.
 WWAMI “mock” visits: generally more positive results.
 “Aha’s”: institutions that demonstrated intolerance of
disrespectful behavior.
CLER Outcome Examples
 Transitions of care:
 ACGME:
 WWAMI “mock” visits: almost all resident teams using
structured protocols, but limited use of interdisciplinary
teams. Inpatient/outpatient hand-offs remain challenging.
 “Aha’s”:
 Observing effective resident to resident patient care
transition.
 Nurses engaging with residents in transitioning patient
care.
Approaching CLER: benefits
 These are ALL critical areas for patient care and
resident education
 Sponsoring institutions in general are highly
enthusiastic about increasing engagement with
GME programs around mutual goals of importance
 Important opportunities for resident and faculty
innovation and systems improvement
Approaching CLER: benefits
 Sample Quality recommendation themes
 Form CLER Committee to identify opportunities for




resident and faculty engagement, without unduly
burdening schedules with committee assignments .
Create a Quality Curriculum for residents and faculty.
Commit to specific initiatives that address health care
disparities.
Increase education around Core Measures and other
hospital-based measures.
Identify mutual goals for inpatient and outpatient activities.
Approaching CLER: concerns
 “One more thing to have to do….”
 History of limited effective engagement of the SI with its
sponsored program.
 For family medicine, little integration of inpatient and
outpatient goals and strategies.
 Lack of resources (espec IT) locally to facilitate the changed
expectations.
 Burden of CLER visit itself.
What to Do Now?
 Build relationships with Healthcare System Leadership
 Clinical integration into health system
 Patient safety/quality promotion
 Participate in health systems’ goals and initiative
development
 Educate leadership on Institutional Requirements and CLER
process
 Educate residents, hospital staff, and faculty on likely
questions and progress meeting health system goals
 Engage your residents and faculty in strategic planning for
including CLER goals
What to Do Now?
 Patient safety: include residents in real, meaningful
experiences:
 Root cause analysis
 Patient safety reporting
 Quality:
 Obtain clinical effectiveness data
 LEAN/RPIW teams
 Work with SI leadership, including safety and quality officers
(one should be on GMEC)
 Include residents in SI initiatives in patient safety, quality
improvement, and addressing health care disparities
What to Do Now?
 Implement meaningful policies for
supervision and duty hours
 Develop transitions of care protocols
 Provide fatigue management/mitigation
training
 Develop monitored standards for
professionalism
Summary: CLER visits
 CLER “mock” visits can be powerful tools to facilitate
collaboration between SIs and programs on mutually
beneficial goals and strategies regarding health care
quality.
 CLER discussions can increase value of program to SI.
 All participants perceived high value in this
collaboration, but also expressed significant
apprehension about the time and resources required,
particularly inadequate data systems.
Resources: CLER visits
 CLER Pathways to Excellence (ACGME):
 https://www.acgme.org/acgmeweb/Portals/0/PDFs/CLER/C
LER_Brochure.pdf
 CLER Site Visit Instructions (ACGME):
 https://www.acgme.org/acgmeweb/Portals/0/PDFs/CLER/C
LERSiteVisitInstructions.pdf
 Consider a “mock” CLER visit from the Network!