1. Lessons for Single-Program Institution Family Medicine Residency Programs about the NAS Institutional Reviews (IR) and Clinical Learning Environment Reviews (CLER) Ardis Davis, MSW Russell Maier, MD Judith Pauwels, MD Family Medicine Residency Network, Univ of Washington

2. Disclosures None to declare

3. Learning Objectives Participants will: Learn about current requirements for FM residencies around CLER (mostly) and IR (less so) Identify some unique challenges for programs in community-based programs located in Single- Program institutions and how we have dealt with them Leave this lecture-discussion session with at least one idea for how our lessons might generalize to approaching your own preparedness

4. Background We have more learnings to share about CLER than IR at this time Focus of this discussion session will be on what we in WWAMI have learned about CLER through our “Mock-CLER Visit Program” Who are we in “WWAMI”?

5. Network Programs ALASKA Alaska Family Medicine Residency (Anchorage, AK) IDAHO Family Medicine Residency of Idaho (Boise) –Caldwell Idaho Rural Training Track –Twin Falls Magic Valley Idaho Rural Training Track Idaho State University Family Medicine Residency (Pocatello) Kootenai Clinic Family Medicine Coeur d’Alene MONTANA Family Medicine Residency of Western Montana (Missoula, MT) Montana Family Medicine Residency (Billings and Kalispell) WYOMING University of Wyoming Family Medicine Residency, Casper University of Wyoming Family Medicine Residency, Cheyenne WASHINGTON Central Washington Family Medicine (Yakima) –Ellensburg Rural Training Track Community Health Care Family Medicine Residency (Tacoma) East Pierce Family Medicine (Puyallup) Family Medicine of Southwest Washington (Vancouver) Group Health Family Medicine Residency (Seattle) Kadlec Family Medicine Residency (Richland) Madigan Army Medical Center Family Medicine (Tacoma) Providence St. Peter Hospital (Olympia) –Chehalis Rural Training Track Puget Sound Family Medicine, Naval Hospital (Bremerton) Spokane Family Medicine –Colville, Washington Rural Training Track Swedish Family Medicine First Hill (Seattle) Swedish Family Medicine Cherry Hill (Seattle) Tacoma Family Medicine University of Washington Academic Medical Centers (Seattle) Valley Family Medicine (Renton) Programs in Development -Harrison Medical Center/Franciscan Health System (Bremerton, WA) -SeaMar CHC (Marysville, WA) -Several potential RTTs

7. AKAK IDID MTMT Annually the Network Convenes… Faculty Development Fellows Program Directors Coordinators  Behavioral Scientists  Chief Residents  4x 1x 5x Participants Chat Family Medicine Residency Network - Monthly webinars - Email groups - Digital resource library Distance Communication and Networking University of Washington | Seattle WYWY WAWA  

8. Background: Institutional Accreditation Process Internal review process: –Annual Institutional Review (AIR) –Special Review oversight, if need External review processes: –Clinical Learning Environment Review (CLER) –Periodic Institutional Reviews

9. 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.”

10. CLER Focus Areas Professionalism Supervision Healthcare Quality Healthcare Disparities Transitions of Care Duty Hours Fatigue Management Patient Safety

11. CLER Issues for Single Program SIs Who is the SI: alternative structures History of limited effective engagement of the SI with its sponsored program. For family medicine and primary care training, little integration of inpatient and outpatient goals and strategies. Lack of resources locally to facilitate the changed expectations.

12. WWAMI’s CLER “Mock” Visits: Enhancing “Quality” Conversations Objective –Determine the impact of a “mock” CLER visit on health care quality initiatives in single- program sponsoring institutions and their family medicine residency programs

13. WWAMI’s CLER “Mock” Visits: Method “Mock” CLER visit model developed using “CLER Pathways to Excellence” and information from the ACGME on CLER visit process Specific intent on initiatives benefitting both the SI and the residency program

14. WWAMI’s CLER “Mock” Visits: Method: Materials Handout to be used to help educate those unfamiliar with CLER, such as hospital leadership Copy of the “pathways to excellence” developed by the ACGME to discuss the expectations and opportunities they envision Detailed process example that was used when planning the CLER visit List of questions that might be used during interviews Report template

15. WWAMI’s CLER “Mock” Visits: Method: Process Handout to be used to help educate those unfamiliar with CLER, such as hospital leadership Copy of the “pathways to excellence” developed by the ACGME to discuss the expectations and opportunities they envision Detailed process example that was used when planning the CLER visit List of questions that might be used during interviews Report template

16. WWAMI’s CLER “Mock” Visits: Results: “Quality” outcomes –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.

17. WWAMI’s CLER “Mock” Visits: Results: “Quality” outcomes –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 Similar results

18. WWAMI’s CLER “Mock” Visits: Results: “Quality” outcomes –Overall 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.

19. WWAMI’s CLER “Mock” Visits: Results: Perceived Benefits SI leadership: –Quality focus: 26/35. –Benefits in highlighting “gaps”. Program leadership: –Quality focus: 16/20. –Plans for increased resident engagement, connection to hospital quality systems.

20. WWAMI’s CLER “Mock” Visits: Significance 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 increased 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

21. Questions and Discussion What challenges have you faced? How are they similar or different from what we have described? How might any of what we have shared generalize to you and your institution/program? Is there one take-away?

22. Please evaluate this session at: stfm.org/sessionevaluation