## Appendix A1. General Characteristics of Sponsoring Institutions

^{a} Percentages do not total 100 because of rounding.

^{b} Limited to 3 Sponsoring Institutions (SIs) in Puerto Rico.

Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; CLER, Clinical Learning Environment Review.

^{a} Percentages do not total 100 because of rounding.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year; SI, Sponsoring Institution.

## Appendix A2. General Characteristics of Clinical Learning Environments

^{a} Based on the 2015 American Hospital Association Annual Survey.

^{b} Percentages do not total 100 because of rounding.

^{c} Member of Council of Teaching Hospital of the Association of American Medical Colleges.

^{d} Includes psychiatric, rehabilitation, acute long-term care hospital, children's general medical and surgical, and other types of services.

^{e} Missing data < 9%.

^{f} Missing data < 14%.

^{g} Missing data < 25%.

^{h} Physicians, residents, interns, and other trainees omitted from staff count.

^{I} Full-time and part-time personnel only; excludes full-time and part-time equivalent personnel.

Abbreviations: CLER, Clinical Learning Environment Review; IQR, interquartile range; SI, Sponsoring Institution.

## Appendix A3. Clinical Learning Environments Visited: Number of Programs at Site

^{a} Based on the 2017 Accreditation Council for Graduate Medical Education data.

^{b} Percentages do not total 100 because of rounding.

Abbreviation: SI, Sponsoring Institution.

## Appendix A4. CLER Visits: Characteristics of Groups Interviewed

^{a} Based on audience response system data.

^{b} Missing data (< 2%) have been omitted; percentages based on valid percent.

^{c} Percentages do not total 100 because of rounding.

## Appendix B. Selected Results From Resident and Fellow Group Interviews

### B1. Percentage of Residents and Fellows Who Reported Experiencing an Adverse Event, Near Miss/Close Call, or Unsafe Condition

**Percent of Total Surveyed ^{a} (n = 9247)**

**72.7**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B2. Percentage of Residents and Fellows Who Reported Experiencing an Adverse Event, Near Miss/Close Call, or Unsafe Condition and Submitted a Report Through the Clinical Site's Reporting System

**Percent of Total Surveyed ^{a} (n = 6550)**

**49.8**

^{a} Missing data (< 3%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B3. Percentage of Residents and Fellows Who Reported a Near Miss/Close Call Event

**Percent of Total Surveyed ^{a} (n = 9243)**

**23.6**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B4. Percentage of Residents and Fellows Who Reported Receiving Feedback on the Outcome of a Report Submitted^{a} Through the Clinical Site's Reporting System

**Percent of Total Surveyed ^{b} (n = 5388)**

**46.1**

^{a} Report submitted by resident or fellow or through a nurse or supervisor.

^{b} Missing data (< 7%) have been omitted; percentages based on valid percent.

^{c} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{d} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{e} Results based on matched observations; see Methodology (p. 13–18).

^{f} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B5. Percentage of Residents and Fellows (PGY-3 and Above) Who Reported Participating in an Interprofessional (Physicians, Nurses, Administrators, Others) Investigation of a Patient Safety Event (eg, Root Cause Analysis)

**Percent of Total Surveyed ^{a} (n = 6796)**

**37.6**

^{a} Missing data (< 4%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B6. Percentage of Residents and Fellows Who Reported Knowing the Clinical Site's Resources to Support Them if Involved in a Major Patient Safety Event

**Percent of Total Surveyed ^{a} (n = 9199)**

**82.3**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: IQR, interquartile range; PGY, postgraduate year.

### B7. Percentage of Residents and Fellows (PGY-2 and Above) Who Reported Knowing the Clinical Site's Priorities in the Area of Quality Improvement

**Percent of Total Surveyed ^{a} (n = 8942)**

**78.8**

^{a} Missing data (< 2%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B8. Percentage of Residents and Fellows (PGY-2 and Above) Who Reported Participating in a Quality Improvement Project of Their Own Design or One Designed by Their Program or Department

**Percent of Total Surveyed ^{a} (n = 8931)**

**78.3**

^{a} Missing data (< 2%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B9. Percentage of Residents and Fellows (PGY-2 and Above) Who Reported Participating in a Quality Improvement Project Linked to 1 or More of the Clinical Site's Quality Improvement Goals

**Percent of Total Surveyed ^{a} (n = 6820)**

**48.2**

^{a} Missing data (< 3%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B10. Percentage of Residents and Fellows (PGY-2 and Above) Who Reported Being Engaged in Interprofessional Quality Improvement Teams (eg, Nurses, Administrators, Pharmacists, etc) While Participating in a Quality Improvement Project Directly Linked to 1 or More of the Clinical Site's Quality Improvement Goals

**Percent of Total Surveyed ^{a} (n = 3214)**

**74.3**

^{a} Missing data (< 3%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B11. Percentage of Residents and Fellows Who Reported Receiving Aggregated or Benchmarked Quality Performance Data About the Care of Their Own Patients

**Percent of Total Surveyed ^{a} (n = 9198)**

**30.9**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; IQR, interquartile range; PGY, postgraduate year.

### B12. Percentage of Residents and Fellows Who Reported Knowing the Clinical Site's Priorities With Regard to Addressing Health Care Disparities

**Percent of Total Surveyed ^{a} (n = 9222)**

**55.1**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B13. Percentage of Residents and Fellows Who Reported Receiving Cultural Competency Training Specific to Populations at Risk for Health Care Disparities at Their Clinical Site

**Percent of Total Surveyed ^{a} (n = 9171)**

**33.6**

^{a} Missing data (< 2%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: IQR, interquartile range; PGY, postgraduate year.

### B14. Percentage of Residents and Fellows Who Reported Participating In a Quality Improvement Project Focused on Reducing Health Care Disparities

**Percent of Total Surveyed ^{a} (n = 9222)**

**10.1**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: IQR, interquartile range; PGY, postgraduate year.

### B15. Percentage of Residents and Fellows Who Reported Participating in Training With Nurses and Other Health Care Professionals in How to Transition Patients' Care

**Percent of Total Surveyed ^{a} (n = 8940)**

**61.1**

^{a} Missing data (< 4%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: IQR, interquartile range; PGY, postgraduate year.

### B16. Percentage of Residents and Fellows Who Reported Following Standardized Processes for Handling Transitions of Care From Inpatient to Outpatient

**Percent of Total Surveyed ^{a} (n = 8886)**

**60.2**

^{a} Missing data (< 5%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B17. Percentage of Residents and Fellows Who Reported Following a Standardized Process for Handling Transitions of Care During Handoffs Between Shifts

**Percent of Total Surveyed ^{a} (n = 9193)**

**82.9**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B18. Percentage of Residents and Fellows Who Reported Following a Standardized Process for Handoffs Between Shifts That Included a Standardized Written Template for Communication

**Percent of Total Surveyed ^{a} (n = 7470)**

**75.6**

^{a} Missing data (< 2%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B19. Percentage of Residents and Fellows Who Reported Having Been Placed, or Witnessing One of Their Peers Placed, in a Situation Where They Believed There Was Inadequate Supervision at the Clinical Site (eg, the Attending Was Not Available)

**Percent of Total Surveyed ^{a} (n = 9212)**

**26.8**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B20. Percentage of Residents and Fellows Who Reported Encountering a Physician (Attending Physicians or Consultants) Who Made Them Feel Uncomfortable When Requesting Assistance

**Percent of Total Surveyed ^{a} (n = 9204)**

**45.9**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: IQR, interquartile range; PGY, postgraduate year.

### B21. Percentage of Residents and Fellows Who Reported Knowing What They Were Allowed to Do Without Direct Supervision

**Percent of Total Surveyed ^{a} (n = 9100)**

**94.0**

^{a} Missing data (< 2%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B22. Percentage of Residents and Fellows Who Reported Having an Objective Way to Know What Procedures Residents and Fellows From Other Services Were Allowed to Do Without Direct Supervision When They Consulted on Patients

**Percent of Total Surveyed ^{a} (n = 9075)**

**38.2**

^{a} Missing data (< 3%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B23. Percentage of Residents and Fellows Who Reported That They Would Power Through to Handoff if Placed in a Situation in Which They Were Impaired by Fatigue, Maxed Out on Caffeine, and a 15-Minute Nap Had No Effect

**Percent of Total Surveyed ^{a} (n = 9184)**

**48.1**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B24. Percentage of Residents and Fellows Who Reported That Their Clinical Site Provided a Supportive, Nonpunitive Environment For Coming Forward With Concerns Regarding Honesty in Reporting (eg, Patient Data, Duty Hours)

**Percent of Total Surveyed ^{a} (n = 9219)**

**88.1**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B25. Percentage of Residents and Fellows Who Reported They Had Documented a History or Physical Finding in a Patient Medical Record That They Did Not Personally Elicit at the Clinical Site (eg, Copying and Pasting From Another Note)

**Percent of Total Surveyed ^{a} (n = 9186)**

**36.4**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

### B26. Percentage of Residents and Fellows Who Reported Having Felt Pressured to Compromise Their Honesty or Integrity to Satisfy an Authority Figure During Their Training at the Clinical Site

**Percent of Total Surveyed ^{a} (n = 9214)**

**14.6**

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) omitted to ensure anonymity.

^{c} Distribution includes 95% or more of the total number of CLEs (N = 287).

^{d} Results based on matched observations; see Methodology (p. 13–18).

^{e} The horizontal line in the middle of the box indicates the median, and the top and bottom of the box indicate the 75th and 25th percentiles, respectively, also known as the interquartile range (IQR). The whiskers above and below the box mark the maximum and minimum values, respectively. The points beyond the whiskers are outliers.

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviations: CLER, Clinical Learning Environment Review; PGY, postgraduate year.

## Appendix C. Selected Qualitative Results From CLER Site Visit Reports

### C1. Percentage of CLEs That Tracked the Number of Patient Safety Event Reports Submitted by Residents and Fellows^{a}

^{a} Missing data (< 5%) have been omitted; percentages based on valid percent. Of note, data are missing largely due to the development and refinement of a formal written site visit report template in the early stages of program implementation.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

^{c} Results based on matched observations; see Methodology (p. 13–18).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviation: CLER, Clinical Learning Environment Review.

### C2. Percentage of CLEs by Proportion of Nurses' Understanding of Reportable Patient Safety Events

^{a} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

### C3. Percentage of CLEs Where Residents and Fellows Frequently Submitted Patient Safety Event Reports^{a}

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent. Of note, data are missing largely due to the development and refinement a formal written site visit report template in the early stages of program implementation.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

### C4. Percentage of CLEs by Proportion of Resident and Fellow Knowledge of Basic Patient Safety Terminology and Principles

^{a} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

^{b} Results based on matched observations; see Methodology (p. 13–18).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviation: CLER, Clinical Learning Environment Review.

### C5. Percentage of CLEs by Proportion of Resident and Fellow Knowledge of Basic Quality Improvement Concepts

^{a} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

^{b} Results based on matched observations; see Methodology (p. 13–18).

Abbreviation: CLER, Clinical Learning Environment Review.

### C6. Percentage of CLEs by Proportion of Resident and Fellow Quality Improvement Projects With Components of a Complete Quality Improvement Cycle

^{a} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

### C7. Percentage of CLEs With Handoff Processes That Were Standardized Across Programs, Based on Direct Observations^{a}

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent. Of note, data are missing largely due to the development and refinement of a formal written site visit report template in the early stages of program implementation.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

^{c} Results based on matched observations; see Methodology (p. 13–18).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviation: CLER, Clinical Learning Environment Review.

### C8. Percentage of CLEs by Mechanism Used for Identification of Resident and Fellow Competency to Perform Clinical Procedures, as Reported by Nurses

^{a} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

^{b} Results based on matched observations; see Methodology (p. 13–18).

Abbreviation: CLER, Clinical Learning Environment Review.

### C9. Percentage of CLEs Where Patient Safety and Quality Leaders Recalled Patient Safety Events Related to Resident and Fellow Fatigue^{a}

^{a} Missing data (< 1%) have been omitted; percentages based on valid percent. Of note, data are missing largely due to the development and refinement of a formal written site visit report template in the early stages of program implementation.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

^{c} Results based on matched observations; see Methodology (p. 13–18).

Abbreviation: CLER, Clinical Learning Environment Review

### C10. Percentage of CLEs Where Residents and Fellows Reported Observing Some Signs of Burnout Among Faculty Members and Program Directors^{a}

^{a} Missing data (< 7%) have been omitted; percentages based on valid percent. Of note, data are missing largely due to the development and refinement of a formal written site visit report template in the early stages of program implementation.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

### C11. Percentage of CLEs Where Executive Leadership Recalled Incidents Concerning Professionalism

^{a} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.

^{b} Results based on matched observations; see Methodology (p. 13–18).

^{*} Statistically significant at *P* < .05.

^{**} Statistically significant at *P* < .01.

^{***} Statistically significant at *P* < .001.

Abbreviation: CLER, Clinical Learning Environment Review.

### C12. Percentage of CLEs With Reports of Chronic Disrespectful or Disruptive Behavior Across More Than 1 Clinical Unit^{a}

^{a} Missing data (< 2%) have been omitted; percentages based on valid percent. Of note, data are missing largely due to the development and refinement of a formal written site visit report template in the early stages of program implementation.

^{b} Results from clinical learning environments (CLEs) in Puerto Rico (1%) have been omitted to ensure anonymity.