I’m CLER, You’re CLER, We’re All CLER By Lynne Meyer, PhD, MPH February 2017

What is CLER? CLER Site Visits are required by the ACGME every 18-24 months (similar style to JCAHO) 1st: December 2014 FEBRUARY 14-16, 2017 Focuses on the institution’s learning environment, not just a specific residency or fellowship program Effective July 2013 for all ACGME-accredited programs

Who’s involved? EVERYONE Program Directors Faculty Resident/Fellows Hospital Administration Nurses/Technicians/Pharmacists, etc.

CLER’s 6 Focus Areas Patient Safety Quality Improvement (including Health Disparities) Transitions in Care Duty Hours, Fatigue Management & Mitigation Supervision Professionalism

CLER Focus Areas Integration of residents into institution’s Patient Safety programs, and demonstration of impact including opportunities for residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care

Housestaff Quality and Patient Safety Committee Mission Statement: Improve integration and participation of housestaff into the institutional quality and safety initiatives and improve quality and safety culture among housestaff, resulting in improved safety for patients at UF&Shands. Meet monthly Subcommittee of the Graduate Medical Education Committee Members are expected to share information with their departments

Quality and Patient Safety Sentinel events AND Near Misses/Close Calls Multiple perspectives are important, not just the nurse’s – you may have the missing piece of the puzzle Without data, we can’t improve

Examples of Medical Errors Failure to employ indicated tests Error in the dose or method of using a drug Failure to provide prophylactic treatment Failure of communication Equipment failure

Why Report Near Misses Not wait for harm to occur Trigger improvements in weak spots in the care process Alert others for possible vulnerabilities and training gaps Contribute to planning, recovery testing, harm mitigation strategies following events that do result in harm

Resident and Attending PSR Reporting by Yearly Quarter

CLER Focus Areas Integration of residents into institution’s Quality Improvement programs and efforts to reduce Disparities in Health Care Delivery, and demonstration of impact including how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes

Quality Improvement Project Registry (QIPR) Pronounced kip-per ----- Coming soon

QIPR Register your project(s) Find other projects that are of interest to you Find potential mentors for a project See what has already been done in your area of interest Collaborate with others – within and outside of your department QIPR helps expedite whether IRB approval will be needed Use QIPR to access resources to assist with QI/PS project

CLER Focus Area: Transitions in Care Oversight of Transitions in Care including how sponsoring institutions demonstrate effective standardization and oversight of transitions of care We will be implementing a standardized process

Patient Handoffs: A Typical Day on the Wards http://www.youtube.com/watch?v=JzCdoQEYHkY What processes do you use to standardize and improve your handoffs

An example of an effective handoff….. https://www.youtube.com/watch?v=IhKVXGPdmtA&feature=youtu.be

UF Health Shands Standardized Handoff in EPIC Update IT has built a new handoff system in EPIC with I-PASS “bones”.  Will be going from Department to Department to customize Currently working with Surgery, Medicine and Pediatrics. To Do: Review your program’s policies located on New Innovations.

Where to review your handoff, supervision and other policies….

CLER Focus Areas Oversight of Duty Hours Policy, Fatigue Management and Mitigation including how sponsoring institutions: (i) demonstrate effective and meaningful oversight of duty hours across all residency programs institution-wide; (ii) design systems and provide settings that facilitate fatigue management and mitigation; and (iii) provide effective education of faculty members and residents in sleep, fatigue recognition, and fatigue mitigation.

Hypothetical Scenario Discussion There is a maximally fatigued resident two hours before the end of his/her shift. Asked what they would do in this circumstance. Power through and sign off? Notify a supervisor and expect to be taken off of duty? Approach another resident and hope they would take over their responsibilities? Report their tiredness to a supervisor and expect to be asked to stay until the end of the shift? Take some other action?

CLER Focus Areas Establishment, implementation, and oversight of Supervision policies including how sponsoring institutions maintain and oversee policies of supervision concordant with ACGME requirements in an environment at both the institutional and program level that assures the absence of retribution Excerpt from Resident Survey

During nights and weekends, which housestaff can do what? https://bridge.ufhealth.org/shands-nursing/quick-links/ Project in process Many programs done, others wrapping up Site is now available

Housestaff/Procedures/Supervision

Can Search by Housestaff name Procedure Department

CLER Focus Areas Education and monitoring of Professionalism with regard to how sponsoring institutions educate for professionalism, monitor behavior on the part of residents and faculty and respond to issues concerning: (i) accurate reporting of program information; (ii) integrity in fulfilling educational and professional responsibilities; and (iii) veracity in scholarly pursuits Excerpt from ADS Annual Update

High Reliability Organizational culture and processes that radically reduce system failures and effectively respond when failures occur Vigilance Reluctance to simplify Preoccupation with failure Deference to expertise Resilience

Accessing the Patient Safety Report (PSR)…. https://bridge.ufhealth.org Submit a PSR in EPIC Report a PSR event while in a patient record in EPIC and save time because patient information is automatically transferred into IDInc. While reviewing an EPIC patient chart, select “more activities” and then “Patient Safety Report – ID INC” and report the event. Call 24-hour PSR Hotline: 352-538-2635

Physician Directors of Quality (PDQ) List Who is your PDQ? What do they do? assures implementation of best practices and evidence based care promotes a culture of patient safety and quality that includes teamwork and commitment to safe, efficient, effective, equitable and patient-centered care. works collaboratively with the CQO, CMO, CNO, hospital quality staff and others

CLER Action Summary We must document what we teach, what we learn and outcomes for: Patient Safety – report using the PSR system, disseminate QI/PS project findings Quality Improvement -- if on a QI/PS project – document in New Innovations (NI) -- coming soon: QIPR Transitions in Care – used a standardized process such as I-PASS (coming soon in EPIC), document that you have reviewed your program’s policies in NI, Duty Hours, Fatigue Management & Mitigation – duty hour logs & didactics Supervision -- document review of your program’s policies in NI, use the New Innovation Logger: Privileged Residents/Search feature. Professionalism Do you use the PSR system when indicated? Do you use and document interpreters as necessary? Do you review the goals and objectives and expectations with your learners? Do you provide your learners with timely, effective feedback? (formative) Do you return your evaluations on time with meaningful, timely data/comments? (summative)

https://bridge.ufhealth.org/poweroftogether/

Read more about it: https://bridge. ufhealth

2017 UF Health Quality Goals Reduce Variation Reduce All-cause Readmission Rate by 3% Reduce Sepsis LOS/Mortality by 5% Increase Value Reduce LOS O/E by 2% Transform Our Culture Increase PSR Reporting by 5% Decrease Serious Safety Event Rate by 20% Zero Harm Reduce Mortality O/E by 3% Reduce CLABSI/CAUTI Rate by 3% Perfect Patient Experience Increase RN Communication by 2% Increase MD Communication by 1% Increase Quietness by 1% Increase Cleanliness by 3% Quality Job #1

How would you answer these? What areas have the hospital identified as opportunities for improvement? Do you know how your individual QI and patient safety projects relate to the hospital’s overall plan in addition to departmental plans? How are health care disparities and health disparities reduced? What are the components of your QI/PS curriculum? Do program directors and PDQs work together to facilitate learning experiences for residents and fellows?

How would you answer these? What types of patient safety activities are residents/fellows involved in? What type of experience do resident or fellow have with RCAs? Are QI/PS projects team projects that are interprofessional and interdisciplinary? Are residents/fellows involved in at least 2 PDSA cycles? When is it necessary to submit a PSR? Who should report PSRs?

How would you answer these? How effective is the dialogue during hand-offs? Are the hand-offs standardized and are they observed/evaluated? How effective are educational efforts around sleep and recognizing and preventing fatigue? Is the level of supervision you experience adequate for the residents’/fellows’ level of training? How likely are residents/fellows to “power through” a shift?

Sites with Curriculum and Cases to work through Resources ACGME’s CLER Program http://www.acgme.org/What-We-Do/Initiatives/Clinical-Learning-Environment-Review-CLER Sites with Curriculum and Cases to work through AHRQ Patient Safety Network http://psnet.ahrq.gov/ AHRQ WebM&M Cases http://psnet.ahrq.gov/ VA National Center for Patient Safety http://www.patientsafety.va.gov/index.asp http://www.patientsafety.va.gov/professionals/training/curriculum.asp AAMC Teaching for Quality (Te4Q) https://www.aamc.org/initiatives/cei/te4q/

Resources http://gme.med.ufl.edu/policy-procedures/cler-visit-2017/ https://ufhealth.org/quality-and-patient-safety/welcome https://bridge.ufhealth.org/quality-patient-safety/quality-and-patient-safety-strategic-mission-2016-2020/hospital-goals/ http://gme.med.ufl.edu/policy-procedures/patient-safety/ https://bridge.ufhealth.org/

Questions? lynnemeyer@ufl.edu 352-594-6226