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

2. What is CLER?
CLER Site Visits are required by the ACGME every 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

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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Resident and Attending PSR Reporting by Yearly Quarter

11. 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

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

13. 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

14. 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

15. Patient Handoffs: A Typical Day on the Wards
What processes do you use to standardize and improve your handoffs

16. An example of an effective handoff…..

17. 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.

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

19. 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.

20. 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?

21. 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

22. During nights and weekends, which housestaff can do what?
Project in process
Many programs done,
others wrapping up
Site is now available

23. Housestaff/Procedures/Supervision

24. Can Search by
Housestaff name
Procedure
Department

25. 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

26. 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

27. Accessing the Patient Safety Report (PSR)….
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:

28. 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

29. 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)

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

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

34. 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

36. 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?

37. 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?

38. 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?

39. Sites with Curriculum and Cases to work through
Resources
ACGME’s CLER Program
Sites with Curriculum and Cases to work through
AHRQ Patient Safety Network
AHRQ WebM&M Cases
VA National Center for Patient Safety
AAMC Teaching for Quality (Te4Q)

40. Resources http://gme.med.ufl.edu/policy-procedures/cler-visit-2017/

41. Questions?