In 2012, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Clinical Learning Environment Review (CLER) program as a component of its new accreditation system.1 CLER is an assessment program designed to provide formative feedback to the leadership of sponsoring institutions, their clinical sites, and graduate medical education (GME) programs about desirable attributes of a shared learning environment that encompasses patients, residents, faculty, program directors, and other members of the health care team. CLER assessments are formative; the only requirement is that all ACGME-accredited sponsoring institutions participate in a visit every 18 to 24 months.
From 2012 through 2015, the CLER program conducted 297 visits and reported the results in the May 2016 supplement of the Journal of Graduate Medical Education (JGME).2 Central to the program is the question of its effectiveness in identifying challenges and opportunities related to its areas of focus, and its ability to affect positive change in these dimensions.
The ACGME continually seeks feedback on programmatic impact. A few weeks after each site visit, the designated institutional official (DIO) receives a written report of findings and is encouraged to submit a response. The responses offer the DIO an opportunity to provide feedback on the site visit experience and share plans for how institutional leadership intends to use the findings to improve the clinical learning environment. The ACGME then shares these responses with the CLER Evaluation Committee, which provides oversight and guidance on the program.
In the first set of visits, 50% of DIOs submitted a response. While essential, this feedback was voluntary, and it may not have reflected all perspectives within the larger DIO community. To assess the impact of the CLER program, in 2015–2016 the ACGME conducted a national survey of DIOs and published the results in the July 1, 2016, issue of JGME.3
We read with interest work by Long et al,4 who report the results of their national survey of DIO perceptions of the CLER program. To our knowledge, their survey is the first national study of the CLER program conducted independently of the ACGME. It is reassuring that on many dimensions the results are consistent with the findings of the prior ACGME survey.3
Long and colleagues4 report that nearly two-thirds of executive leaders viewed the CLER experience positively, and nearly one-third of DIOs reported receiving new resources in 1 or more of the CLER focus areas. It appears that these added resources are allocated in the absence of an ACGME requirement. This finding suggests that the GME community is leveraging the CLER program to advance resident education and engagement in improving patient safety, health care quality, and the other areas of focus.
Long et al4 also identified opportunities to improve aspects of the CLER program, which is consistent with the CLER team's focus on addressing administrative and other challenges.
Of note is the communicated interest in having more advanced notice of the date of the site visit. The CLER program intentionally designed the visits to be short notice, with the intent of minimizing formal preparation and rehearsed responses. The survey by Long et al4 suggests that 44% of sites coached residents and faculty for the visit, versus broadly educating them in the tenets of CLER. Unfortunately, this challenges the CLER program's purpose of promoting unrehearsed conversation and everyday advancement of quality and safety.
As the CLER program is preparing for its third wave of site visits, we look forward to using information from the survey by Long and colleagues, along with other input, to assist the ACGME on its journey toward continual improvement of the program's structure.
