Utilizing Resident Ambassadors as Mock CLER Site Team Members Open Access

From previous Clinical Learning Environment Review (CLER) site visits we know that the walking rounds process may feel intimidating. In addition to didactics regarding CLER, our team explored other meaningful experiences for residents to learn about the CLER walking rounds process. We launched a pilot project during which residents served as Mock CLER site team members.

First, we sent an email to our 30 residency programs explaining the pilot idea and soliciting 1 to 2 residents to serve as the simulated Mock CLER site visit team (Resident Ambassadors). Participating residents (N=368) could use this project as one of their required quality improvement projects. We were able to recruit Resident Ambassadors from the following programs: surgery (1), emergency medicine (1), obstetrics and gynecology (2), and internal medicine (1).

Second, we developed a 23-question survey to assess the current knowledge of the selected 4 Resident Ambassadors. Topics included: health care-associated infections being monitored by the hospital, resident involvement in improving patient safety and care quality, training about interacting with people from other cultures, addressing health disparities during patient care, training in quality improvement (QI), resources for trainees in times of distress, and anonymous reporting options. We also used these survey questions to frame sample questions used by Resident Ambassadors for the Mock CLER walking rounds.¹ 

Third, over the course of 2 to 3 weeks, the CLER Resident Ambassadors made unannounced, on-the-spot Mock CLER site visit interviews with program residents during regularly scheduled clinical assignments. Resident Ambassadors explained their role and the goals of the pilot Mock CLER program.

Eighty-one of the 410 residents completed the survey (20%), and 77 of the 81 (95%) reported their postgraduate year (PGY). The PGY-2s were the highest group completing the survey (21 of 77, 27%); second were the PGY-3s (19 of 77, 25%); and third were the PGY-1s (16 of 77, 21%). The remaining PGY-4, PGY-5, and PGY-6 residents had a combined total of 21 of 77 (27%). Three themes emerged: (1) over half of residents did not feel confident discussing the hospital’s QI initiatives, but most could identify its clinical performance improvement areas; (2) most were not comfortable discussing health disparities; and (3) most knew how to report issues anonymously and felt safe doing so.

During the Mock CLER walking rounds, the Resident Ambassadors interviewed 48 residents: surgery (10), obstetrics and gynecology (14), emergency medicine (10), and internal medicine (14). Questions posed during walking rounds provided new opportunities for peer dialogue about patient safety and quality improvement that otherwise were unlikely during typical clinical assignments. Although the live questioning process was part of the Mock CLER site visit, residents found the process challenging due to interruptions of the service’s workflow. Further, residents reported experiences that were highly similar to those during actual CLER site visits and felt they did not answer questions as well as they would have liked.

Based on experiences and feedback, we are initiating improvements. We shall continue the Mock CLER site visit using Resident Ambassadors, but we added a member of the hospital’s CLER Executive Committee on the walking rounds (beginning February 2024). To expedite the Mock CLER site visit, we are creating a 1-page answer sheet for Resident Ambassadors to use when answering questions from residents during the visit. Our hospital’s chief medical officer helped start a 2-part CLER grand rounds for all training programs (part 1 in summer 2023; part 2 in January 2024). In winter 2023, we piloted a CLER newsletter. Reviews were positive, and many programs use it as part of their CLER education. A surgery faculty member will become the newsletter editor, and residents and faculty will be encouraged to submit materials related to the clinical learning environment (fall 2024). We shall continue to strive for an optimal learning environment, and as the CLER Resident Ambassadors program continues to evolve, we anticipate our community of learners will benefit because CLER safety objectives inform our activities.