Appendix A1. General Characteristics of Sponsoring Institutions
Sponsoring Institution Distribution by Number of ACGME-Accredited Residency and Fellowship Programs and Participating Sitesa

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.
Number and Distribution of Core Faculty Members at Sponsoring Institutions by Specialty Groupinga

Number and Distribution of Residents and Fellows at Sponsoring Institutions by Gender, Level of Training, and Specialty Groupinga

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
Selected Characteristics of Residents and Fellows in the Group Interviewsa

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 Surveyeda (n = 9247)
72.7
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 6550)
49.8
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9243)
23.6
Distribution Across CLEsc (n = 286)
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 Submitteda Through the Clinical Site's Reporting System
Percent of Total Surveyedb (n = 5388)
46.1
Distribution Across CLEsd (n = 286)
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 Surveyeda (n = 6796)
37.6
Distribution Across CLEsc (n = 280)
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 Surveyeda (n = 9199)
82.3
Distribution Across CLEsc (n = 284)
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 Surveyeda (n = 8942)
78.8
Distribution Across CLEsc (n = 280)
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 Surveyeda (n = 8931)
78.3
Distribution Across CLEsc (n = 280)
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 Surveyeda (n = 6820)
48.2
Distribution Across CLEsc (n = 280)
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 Surveyeda (n = 3214)
74.3
Distribution Across CLEsc (n = 279)
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 Surveyeda (n = 9198)
30.9
Distribution Across CLEsc (n = 282)
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 Surveyeda (n = 9222)
55.1
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9171)
33.6
Distribution Across CLEsc (n = 284)
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 Surveyeda (n = 9222)
10.1
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 8940)
61.1
Distribution Across CLEsc (n = 275)
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 Surveyeda (n = 8886)
60.2
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9193)
82.9
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 7470)
75.6
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9212)
26.8
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9204)
45.9
Distribution Across CLEsc (n = 282)
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 Surveyeda (n = 9100)
94.0
Distribution Across CLEsc (n = 280)
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 Surveyeda (n = 9075)
38.2
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9184)
48.1
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9219)
88.1
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9186)
36.4
Distribution Across CLEsc (n = 286)
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 Surveyeda (n = 9214)
14.6
Distribution Across CLEsc (n = 286)
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 Fellowsa
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
Percentage of CLEs Where Most Nurses Had an Understanding of Reportable Patient Safety Events, by CLE Characteristics

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 Reportsa
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
Percentage of CLEs Where Most Residents and Fellows Had a Working Knowledge of Patient Safety Principles, by CLE Characteristics

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
Percentage of CLEs Where Most Residents and Fellows Had a Working Knowledge of Quality Improvement Concepts, by CLE Characteristics

Change Between CLER Visits: Cycle 1 and Cycle 2b (n = 220)
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
Percentage of CLEs Where Most Resident and Fellow Quality Improvement Projects Had Components of a Complete Quality Improvement Cycle, by CLE Characteristics

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 Observationsa
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
Change Between CLER Visits: Cycle 1 and Cycle 2b (n = 237)
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 Fatiguea
Change Between CLER Visits: Cycle 1 and Cycle 2c (n = 200)
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 Directorsa
Percentage of CLEs Where Residents and Fellows Reported Observing Signs of Burnout, by CLE Characteristics

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 Unita
Percentage of CLEs With Reports of Chronic Disrespectful or Disruptive Behavior, by CLE Characteristics

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.