Introduction to the CLER National Report of Findings 2018

The Clinical Learning Environment Review (CLER) Program has been designed and implemented as a formative learning process for each Sponsoring Institution (SI), the graduate medical education (GME) community, the Accreditation Council for Graduate Medical Education (ACGME), and the public. Its aim is to provide a continual flow of information about the nation's clinical learning environments (CLEs). While the initial conceptualization for what was to become the CLER Program began as far back as 2009 with the ACGME Duty Hours Task Force1 (subsequently named the ACGME Task Force on Quality of Care and Professionalism), the CLER Program officially launched site visits in September 2012.2,3 

The CLER National Report of Findings 2016 provided baseline information from site visits to CLEs for 297 ACGME-accredited SIs that had 3 or more core residency programs.4 At the time, those SIs represented 92% of all ACGME-accredited residency programs and 90% of all residents and fellows in ACGME-accredited programs.

These findings from the first cycle of CLER Site Visits revealed numerous challenges and opportunities across the 6 CLER Focus Areas: patient safety; health care quality (including health care disparities); transitions in care; fatigue management, mitigation, and duty hours; supervision; and professionalism. The 2016 National Report presented 4 overarching themes identifying how CLEs varied in:

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  their approach to and capacity for addressing patient safety and health care quality and the degree to which they involve residents and fellows in these areas;

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  their approach to implementing GME—in many clinical learning environments, GME is largely developed and implemented independently of the organization's other areas of strategy planning and focus;

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  the extent to which they invest in continually educating, training, and integrating faculty members and program directors in the area of health care quality, patient safety, and other systems-based initiatives; and

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  the degree to which they coordinate and implement educational resources across the health care professions.

ACGME was uncertain how the community would react to the CLER Program and its initial report of findings. The first evidence of its impact came from 2 different national surveys of the community of designated institutional officials (DIOs) of SIs.5,6 Both of these surveys suggested that the CLER visits were providing new information that DIOs and the executive leaders of the hospitals, medical centers, and health systems that comprise the CLEs are using to design and implement new approaches to improving learning and patient care.

ACGME has used the findings from the 2016 National Report as formative feedback to inform its accreditation mission. The findings served as an important foundation for discussions of the ACGME task force that was charged with revising Section VI of the Common Program Requirements. Many of the CLER findings in the areas of patient safety and health care quality provided the task force with clarity on specific areas where ACGME had an opportunity to collectively raise program standards.

In the present CLER National Report of Findings 2018, the CLER Program provides a second look at the CLEs of ACGME-accredited SIs with 3 or more core residency programs. This report provides insight into the current state within these CLEs and the first opportunity to examine temporal changes that appear to be developing across CLEs.

As with the first report, this second report of findings contains several overarching themes. These themes highlight both progress and ongoing opportunities to improve the engagement of residents and fellows in the CLE's patient safety and quality efforts, improve the alignment of GME and CLE executive leadership, and invest in developing faculty members who understand systems-based practice and who can lead efforts to improve patient safety and health care quality. In the fourth theme, this report goes beyond the focus of the 2016 National Report on the need for educational resources that are shared across the health professions and highlights the need for a greater investment in interprofessional learning. This report also highlights 2 additional overarching themes—noting that CLEs are experiencing:

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  increasingly rapid consolidation of health care delivery and its impact on the stability and evolution of GME, and

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  a high degree of perceived faculty member and program director burnout, which presents a very real and immediate problem for both the profession and for patient care.

As previously mentioned, this second National Report provides the first insight into how the nation's CLEs are changing over time. It is encouraging to see some significant improvement in the 6 Focus Areas—most notably in the area of increased resident and fellow engagement in addressing patient safety. The trend toward improved engagement in patient safety exemplifies how formative feedback can simultaneously benefit both patient care and the resident learning experience.

As might be expected, given the broad scope of the 6 CLER Focus Areas and the diversity of the SIs visited, the direction and pace of change noted in the 2018 National Report is uneven. Some of the Focus Areas, such as health care quality, are amenable to direct intervention with tools that make rapid change possible. Other areas, such as professionalism, will require a deeper exploration into the culture of each CLE and long-term strategic interventions where culture must be modified.

This second set of CLER Site Visits that informed the present National Report began in 2015, around the same time that the ACGME became acutely aware of professional stress manifested in burnout, depression, and, tragically, deaths by suicide. One of the ACGME's early actions as a result of this awareness was to have the CLER Program start to explore these issues on the CLER Site Visits. As noted in the present report, the findings from these visits suggested a distressingly prevalent degree of burnout affecting faculty members and program directors across CLEs. On the basis of preliminary findings from these visits, the ACGME Board of Directors approved changing 1 of the CLER Focus Areas (fatigue management, mitigation, and duty hours) to that of “Well-Being” and encouraged the CLER Program to conduct a more in-depth exploration of the topic. Subsequent CLER reports of findings will provide much deeper insight into how CLEs are responding to these challenges. In addition, over time, the CLER Program will provide valuable input to the efforts of ACGME7 and the National Academy of Medicine8 in assisting CLEs as they address this national challenge.

This and subsequent CLER reports of findings, when taken in total, provide a formative tool that monitors the changes in CLEs. Trends, at the institutional as well as the national level, will demonstrate the degree of improvement in these dimensions of the CLE. More importantly, the findings provide insights into where and how to intentionally effect change. Some of the challenges identified by the findings will likely best respond to a regulatory approach, which could inform the development of standards. For example, it will be noteworthy to see if the enhanced focus on patient safety in the new Common Program Requirements9 will aid in accelerating change as observed by CLER in this area. Other challenges will require deeper cultural change that might best respond to collaborative approaches that bring together organizations that address medical education and organizations that view CLEs as a place for shared interprofessional learning.

While potentially informing standard setting, the CLER Program will continue to remain formative and entirely separate from the accreditation function of the ACGME. Its goal differs from that of accreditation. Namely, the CLER Program is designed to assist SIs and their programs in their quest to achieve excellence in key domains that contribute meaningfully to patient care and resident learning that are part of the unwritten curriculum and culture of the SI.

ACGME is piloting a more intensive variant of this type of cooperative approach through the Pursuing Excellence Initiative (PEI). PEI is a 4-year effort to bring SIs together to build a national learning community to address the CLER Program's findings. The first effort within PEI is a collaborative that convenes 8 SIs who have committed to working together over a 4-year period to develop and test innovative solutions to address the challenges identified in the overarching themes noted in the first CLER National Report. Their efforts to date include designing and implementing new faculty development programs for enhancing skills in the areas of patient safety and health care quality. They are also working on novel approaches to enhance interprofessional learning.

The PEI initiative has also recently started a separate learning collaborative with 9 SIs to embrace the goal of ensuring that residents and fellows fully engage in activities to improve patient safety within their first year of training.

The PEI initiative is ACGME's effort to support the community to develop successful solutions to the issues identified by the CLER Site Visits. Ultimately, innovation within the nation's CLEs has to come from activated leaders of the GME community and executive leaders of the CLEs and their respective health systems.

To further advance learning around the findings from the first CLER National Report, ACGME has been a principal sponsor of the National Collaborative for Improving the Clinical Learning Environment (NCICLE). NCICLE is an interorganizational collaborative in which over 30 organizations share an interest in improving learning in the clinical environment. Late in 2017, NCICLE sponsored what appears to be one of the first national conversations to focus on the interprofessional CLE with the express interest in advancing the quality of this shared space where learning takes place in the context of patient care.10 

The CLER Program itself continues to evolve based on the findings from this report. As noted previously, the current CLER visits include an in-depth inquiry into how CLEs are addressing the issue of well-being for residents, fellows, and faculty members, as well as the other members of the clinical care team. Recently, the ACGME Board of Directors approved a new focus area called Teaming. In the future, this focus area will explore how CLEs are formally engaging residents and fellows in learning the nature of teamwork and interprofessional engagement as part of their GME experience. The CLER Program has also launched its first subprotocol exploring how operative and procedural areas serve as CLEs for the CLER Focus Areas. For the first time later this year, a second subprotocol will begin to explore the patient perspective of the CLE. In addition, work is underway to develop a subprotocol to explore how the governance of the nation's CLEs engages in oversight of GME as it relates to the CLE's strategic plan.

The 2018 National Report would not be possible without the commitment of a large community of individuals who support the CLER Site Visit process and related efforts. First, the ACGME appreciates the active participation of GME and CLE executive leadership, the input of the program directors and faculty members, and the collaborative dialogue with nurses and other health care professionals interviewed during walking rounds. In particular, the DIOs are to be commended for their efforts in convening the various stakeholders within their CLE and using the resulting information to create constructive change. The ACGME also extends its appreciation to the institutional coordinators and their administrative teams who work hard to make these visits possible. Credit also goes to the CLER Program team—both ACGME staff and the members of the GME community who have volunteered their time to become CLER Site Visitors. Finally, the ACGME thanks the members of the CLER Evaluation Committee for their successful efforts in synthesizing the immense amount of new qualitative and quantitative data into key concepts and discussions that GME leaders and executive leaders of CLEs can use to effect change.

With the publication of this second CLER National Report, the ACGME demonstrates its continuing commitment to formative assessment as an essential component of a robust GME learning community. The CLER Program, along with the ACGME's Milestone Project, provides the community with several formative approaches to assessment. Coupled with annual accreditation feedback to programs and SIs, the ACGME accreditation system as a whole seeks to support programs and their SIs in their journey to excellence in patient care and education. The information gained from these approaches helps ACGME to be better positioned as a learning organization to best serve its mission of improving the health and health care of the American public through excellence in physician formation through accreditation.