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CLER Overview. Graduate Medical Education Committee April 1, 2013. What is CLER?. C linical L earning E nvironment R eview Component of ACGME’s Next Accreditation System (NAS) . Focus on educational/working environment, not accreditation requirements.

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Cler overview

CLER Overview

Graduate Medical Education Committee

April 1, 2013

What is cler
What is CLER?

  • Clinical Learning Environment Review

  • Component of ACGME’s Next Accreditation System (NAS).

  • Focus on educational/working environment, not accreditation requirements.

  • Review conducted where residents receive their clinical training.

  • Purpose is to ensure that those settings promote quality care and prepare residents to practice safely.

Cler s six focus areas
CLER’s Six Focus Areas

  • Patient Safety

    • Do residents report patient safety issues ? (errors, unsafe conditions, near misses)

    • Do residents participate in inter-professional teams to promote patient safety?

  • Quality Improvement

    • Are GME leadership, faculty, and residents integrated into the hospital’s quality improvement activities?

    • Do residents learn how to identify opportunities for reducing health care disparities?

    • Do residents use data to improve systems of care?

Cler s six focus areas1
CLER’s Six Focus Areas

  • Transitions of Care

    • Is there effective standardization and oversight?

    • Does the hospital facilitate professional development for residents and faculty about transitions of care?

  • Supervision

    • Does the institution establish and monitor policies for effective supervision of residents?

    • Do all residents have protected mechanisms to report inadequate supervision? Do/would they use them?

Cler s six focus areas2
CLER’s Six Focus Areas

  • Duty hours, fatigue management & mitigation

    • Are faculty and residents educated about fatigue?

    • Is there institutional oversight and monitoring of duty hours across all programs?

  • Professionalism

    • Do we educate/monitor behavior of residents & faculty?

    • Is there “veracity in scholarly pursuits?”

    • Is reporting of program information to the ACGME accurate?

    • Do residents report their duty hours accurately?

Cler visits
CLER Visits

  • Every 18 months, for 2-5 days (expect 2-3 days).

  • 10 days to 3 weeks advance notice, any time after January 1, 2013.

  • We will have a CLER visit before February 2014.

  • Hospital leadership will be asked to describe our performance in the six focus areas.

  • Interview meetings and walking tours of clinical areas.

  • First CLER visit will be to University of Utah Hospital only.

  • Results of first visits are baseline and will not be used in making accreditation decisions.

How cler v isit is conducted
How CLER visit is conducted


    • DIO contacted 10 – 21 days ahead of visit.

    • DIO requested to provide documents 1 week prior to visit:

      • Organizational charts, select committee rosters

      • Organizational strategies for patient safety & healthcare quality

      • Policies on supervision, transitions in care, duty hours


    • Team of 2-6 visitors.

      • One volunteer from another institution

      • One or more ACGME professionals

      • Size and membership of team based on size and complexity of Sponsoring Institution

How cler visit is conducted
How CLER visit is conducted

  • Walking tours of clinical areas, conducted by chief residents.

    • 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

  • Team members have returned in the evening.

  • Team provides exit conference to hospital and GME leaders.

Who is interviewed
Who is interviewed?

  • CEO

    • Participation by the CEO in the opening and closing conferences (at minimum) is essential.

  • Other Hospital Leaders

    • CMO, CNO, CHQO

  • GME Leadership

    • DIO, GME office staff, GMEC Chair, GMEC resident members.

  • GME Programs

    • Program Directors, core faculty, peer-selected residents from all core programs and larger fellowships.

Key questions
Key Questions

  • 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?

  • How integrated is the GME leadership and faculty in the current clinical learning environment?

    • What is the role of GME leadership and faculty to support resident and fellow learning in each of the six focus areas?

    • How engaged are the residents and fellows?

  • How does the hospital determine the success of its efforts to integrate GME into the quality infrastructure?

  • What areas have the hospital identified as opportunities for improvement?

What could t hey a sk
What could they ask?

  • Do residents know how to report an adverse event or potential safety concern?

  • Do our residents file reports of safety concerns—or do they leave it to the nursing staff?

  • If a resident reports a concern, does he/she get feedback about what action was taken?

  • Do residents know the hospital’s quality goals?

  • Do residents know how their individual QI and patient safety projects relate to the hospital’s overall plan? Do the faculty members? GME committee?

What are we doing now
What are we doing now?

  • Patient Safety, Quality Improvement, Transitions, Supervision, Duty Hours/Fatigue Management, Professionalism:

    • Follow up with programs on resident concerns raised in annual ACGME and GME Office resident/fellow surveys.

    • Follow up with programs on issues raised in Internal Reviews.

    • Address issues in annual program director retreats and monthly program coordinator training sessions.

    • Require programs with problems to report progress regularly (usually 6 month intervals) to the GME Committee.

    • Ensure that program directors are current in their knowledge of ACGME requirements.

What else are we doing now
What else are we doing now?

  • Duty Hours, Fatigue Management and Mitigation

    • Monitor duty hours in E*Value system; provide quarterly reports to GMEC; request action plans from problem programs.

    • Mandatory work hours/fatigue mitigation session for residents at orientation.

    • SAFER Sleep Deprivation module on GME website.

Where do we need to do more
Where do we need to do more?

  • Quality Improvement and Patient Safety

    • Educate faculty and residents In quality improvement and patient safety.

    • Involve GME leadership, faculty and residents in hospital’s quality and patient safety activities (committees, inter-professional teams, RCAs, etc.).

    • Form resident quality group.

    • Form GMEC patient safety and quality subcommittee.

    • Dedicate Quality Department analyst for GME to track residents’ projects & ensure integration with hospital’s quality system.

  • Transitions of Care

    • Complete development and implement uniform transition of care form for the EPIC EMR (Mike Strong, MD).

Where do we need to do more1
Where do we need to do more?

  • Duty Hours, Fatigue Management

    • Educate Faculty in fatigue management and mitigation.

  • Professionalism

    • Develop education and systems to monitor fulfillment of professional responsibilities, including scholarly pursuits, accurate and honest reporting of duty hours by residents/fellowsand identification of resident mistreatment.

What should we do now
What should we do NOW?

  • Form a CLER Working Group.

  • Brief Hospital leadership, GMEC, faculty and residents.

  • Ensure GMEC and program policies (e.g., supervision, duty hours, transitions of care, fatigue management) and Organizational Charts are up to date.

  • Begin faculty and resident education in quality improvement and patient safety (e.g. IHI Open School courses).

  • Develop orientation for nurses and other staff.

  • Develop tracking systems for actions in each of the six focus areas.

Some practical issues
Some practical issues

  • Short notice scheduling

    • Availability of CEO & other senior leaders

    • Peer-selection of residents/fellows

  • Meeting rooms

    • Multiple meetings of up to 35 persons

    • Screen or clean wall for projection

    • Short notice room reservations

  • Walk-arounds

    • HIPAA/BAA agreements (ours are current)

    • ID badges for visitors

    • Chief resident escorts

    • Nursing and other staff preparation (CNO)

Early impressions from cler visits
Early Impressions from CLER Visits*

  • Transitions of Care

    • Primary focus on hand-off for change of duty

    • Variability in process and oversight of resident hand-offs

  • Supervision

    • Examples of both under and over supervision

    • Knowledge of need for direct supervision appears to be limited to GME faculty

* R. Wagner. ACGME Annual Education Conference, Session 062, March 2, 2013

Early impressions from cler visits1
Early Impressions from CLER Visits*

  • Duty Hours/Fatigue Management

    • Consistent emphasis on education; variable evidence of effective management strategies

  • Professionalism

    • Most residents report being in a culture of openness for bringing forth concerns regarding honesty in reporting

    • Variable monitoring by participating sites

* R. Wagner. ACGME Annual Education Conference, Session 062, March 2, 2013

Early impressions from cler visits2
Early Impressions from CLER Visits*

  • Leadership

    • Significant variability in:

      • Programs working together on inter-program or common-program solutions

      • Programs working together on institutionally-directed solutions

      • Participating site’s leadership view of the strategic value of GME in advancing patient safety and care improvement

      • Participating site’s leadership view of the strategic role of GME in advancing patient safety and care improvement

* R. Wagner. ACGME Annual Education Conference, Session 062, March 2, 2013

For additional information
For additional information: