1. Clinical Learning Environment Review (CLER):
Program Director School
June 12, 2015

2. Good News and Bad News and Good News
Good News: The CLER visit (cycle 2) just took place this week, and they will not be back for months.
Bad News: CLER is an ongoing, open-ended program, which requires continuous attention and work.
Good News: CLER is all about “doing the right thing”, and efforts put forth towards CLER are valuable for all of us

3. Process/Tracking – introduction to MMC CLER Dashboards
CLER - OBJECTIVES
Overview
Process/Tracking – introduction to MMC CLER Dashboards
PD responsibilities
Resources/Who can help get this done?

4. What is CLER?
New (2012) program from the Accreditation Council for Graduate Medical Education (ACGME)
ACGME CLER Website
“To assess the GME learning environment”
“CLER emphasizes the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care”
“The intent of CLER is to generate national data on program and institutional attributes that have a salutary effect on quality and safety in settings where residents learn and on the quality of care rendered after graduation”
“In its initial phase, CLER data will not be used in accreditation decisions by the Institutional Review Committee (IRC)”

5. Process MMC CLER site visit - June 4-5, 2013 Observation & interviews
Group meetings with housestaff, faculty, directors
Audience response system used to collect input
CLER written report - July 30, 2013
Pathways to Excellence document - January 2014
Anticipated “final report” with benchmarking – Summer 2015
Cycle 2 MMC site visit – Tuesday/Wednesday June 9/
Expected to expand interviews to wards: staff and patients

6. CLER Focus Areas Patient Safety
Reporting & participation in promotion of safe care
Quality Improvement
Resident involvement/engagement
Alignment with institutional goals/foci
Transitions in Care
Standardization & oversight
Supervision
Procedural competence
Duty Hours Oversight, Fatigue Management/Mitigation
Professionalism
EHR documentation
Explain meanings of each of these as needed

8. Pearls of CLER Wisdom “Standard does not mean identical”
“Not accreditation – Simply for your own edification”
MMC’s evaluation appears to have been at or above the national average at the time of the Cycle 1 visit
"The CLER visit will continue to be a formative evaluation, built on a model of continuous quality improvement. We look forward to hearing about any goals for improvement and progress toward these goals"

9. Specific Guidelines/Measures

10. A few relevant examples of Pathways/Properties
Healthcare Quality Pathway 1: Education on quality improvement
Residents/fellows receive progressive education and training on QI that involves experiential learning
Residents/Fellows and faculty members are engaged in QI educational activities where the clinical site’s systems-based challenges are presented, and techniques for designing and implementing systems changes are discusses
Faculty members report that they are proficient in clinical quality improvement
Healthcare Quality Pathway 3: Residents/fellows receive data on quality metrics
Residents/fellows receive, from the clinical site, specialty-specific data on quality metrics and benchmarks related to their patient populations

11. “What the CLER Team Finds Really Exciting”
Active and interested engagement of the CEO with the DIO
Reports of CEO and C-Suite [& BOD] taking direct interest in resident/fellow and faculty development
Efforts to engage residents in patient safety investigation
Inter professional (nurses and other clinical staff) quality projects
Resident quality projects leading to substantial improvements
Observing a really good resident to resident care transition

12. “What Else the CLER Team Finds Really Exciting”
Nurses engaging with residents in transitioning patient care
CLE’s demonstrating intolerance of disrespectful behavior
Multi-cultural training that goes beyond language translation
Program Directors working on collaborative efforts around one or more of the six CLER focus areas
Patient Safety leadership engaging with the GME community

13. MMC’s CLER PROCESS Housestaff Quality and Safety Council (HQSC)
“Dashboard”/Gap Analysis on 89 “Pathways to Excellence”
Department Chiefs/Program Directors baseline assessment
Resident/Fellow survey data
Program Director survey data
Faculty survey data
Content Expert meetings
Utilize dashboards to mitigate gaps
Enhance, Share and/or develop new tools/programs
Condense dashboards into an evolving report card, with “menu” of institutional tools, “best practices” and measurement tools for each pathway
Publish/maintain on MERC (Medical Education Resource Center)

14. Dashboard Example: 7 (of 89) Pathways

15. Content Experts for Each Focus Area
Patient Safety: E. Graydon Baker & W. Williams
Quality Improvement: Josh Cutler
Transitions in Care: J. Botler
Supervision: J. Skolfield & B. Bing-You
Duty Hours Oversight, Fatigue Management/Mitigation : J. Skolfield & B. Bing-You
Professionalism: M. Roy

17. PD Responsibilities “Do the right thing”
We’re all in this together – Work together for common goals
CLER encourages interdisciplinary collaboration – “cross-breeding”
Certain elements of CLER fall more cleanly into traditional PD territory….
Duty Hours/Fatigue mitigation
Supervision
…but the bar is being raised
Read (and LIVE) the Pathways to Excellence document, and the National Report of Findings (when available)

18. RESOURCES/WHO CAN HELP?
Everyone!!: CLER is about institutional transformation, evolution of culture and continuous improvement
Other PDs/GMEC
HQSC
Chiefs
Coordinators
CLER Czar - Tom
PSO – Erin
DIO/Assistant DIO
Quality Officer
MITE
MERC
CPI/CORE
Quality and Safety Research group

19. Thank You
Questions/Comments