International Clinical Learning Environment Pathways to Excellence: Executive Summary Open Access

The World Health Organization (WHO) has long recognized inequities in patient safety and quality of care as challenges to achieving the goal of better health care for all.^2,3  More recently, the WHO recognized the role of workforce education as one of the strategic objectives in its global patient safety action toward eliminating avoidable harm in health care.⁴ 

The physician workforce is one of the key levers to improving health care. Resident and fellow physicians who work on the front lines of patient care need to be prepared to recognize patient safety events and intervene when appropriate, to champion performance improvement efforts, and to work effectively in interprofessional teams on systems-based issues. The next generation of the physician workforce needs the skills to contribute to systems improvement in health care organizations globally.

In 2013, the ACGME publicly introduced the concept of the CLE to the GME community in the United States.⁵  The initial version of International Clinical Learning Environment Pathways to Excellence is based on a series of documents subsequently published by the ACGME.^6-8  The ACGME’s Clinical Learning Environment Review (CLER) Program published the first CLER Pathways to Excellence document in 2014. At the time, the CLER Program launched a site visit process to explore the clinical sites that host US GME and provide formative feedback to improve the CLE in 6 cross-cutting Focus Areas, including Patient Safety and Health Care Quality. The CLER Program created the initial and subsequent versions of the CLER Pathways to Excellence to serve as guidance to promote discussions and actions in these 6 cross-cutting Focus Areas to optimize the CLE for GME and patient care. Additionally, in the United States, the National Collaborative for Improving the Clinical Learning Environment noted that CLEs are shared educational experiences and developed a similar document to address learners across the health care professions.⁹ 

Since the inception of the CLER Program, there has been international interest in the concept and practice of high-performing CLEs. By adapting the work of the CLER Program, this document provides guidance that can resonate internationally as educational leaders engage in dialogue with the executive leaders of their CLEs to build or strengthen infrastructure and processes that optimize both learning and patient care.

In each of the 6 CLER Focus Areas, a series of pathways and properties are framed as expectations (Table). Currently, these are neither requirements for ACGME-I accreditation, nor are they intended to serve a regulatory function. They are a framework that can be used to initiate or deepen conversations among GME leaders and health care executives as they strive to optimize the clinical site’s ability to provide high-quality education and safe patient care.

CLEs are shared by many learners—both within medicine and across the health care professions. As such, the guidance within this document can be broadened to encompass resident and fellow physicians in nonaccredited programs, as well as learners from other professions on the clinical care team.

To adapt the CLER Pathways to Excellence for the international community, the leaders of the CLER Program and ACGME-I convened a working group composed of GME leaders (designated institutional officials or their designees) and organizational leaders in patient safety and health care quality improvement from sponsoring institutions accredited by or in dialogue with ACGME-I.

Collectively, the document was informed by inputs from more than 40 participants from 22 sponsoring institutions/organizations across multiple countries, including (in alphabetical order) Guatemala, Haiti, Jordan, Kenya, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Singapore, the United Arab Emirates, and Vietnam, as well as the United States.

To begin this work, the participants reviewed Version 2.0 of the CLER Pathways to Excellence to determine if each property in the 6 Focus Areas needed modification to be more applicable internationally. Participants responded to an initial survey review of the CLER Pathways 2.0 document (ie, pathways and properties) by reviewing each property and marking it “keep as written,” “modify,” or “delete.” Results of the initial review were then collated and used to inform small- and large-group discussions held both in-person and online via videoconference. Overall, most properties in Version 2.0 of the CLER Pathways to Excellence were determined to be applicable and were not modified. Several rounds of iterative discussions and revisions were required to modify approximately one quarter of the properties, and participants reached consensus on the final version.

Central to the International Clinical Learning Environment Pathways to Excellence is a series of pathways for each of the 6 Focus Areas, which are collectively important to create an optimal CLE. Each pathway presents a series of key properties that CLEs, in collaboration with their GME leadership, can implement to optimize resident and fellow physicians’ engagement.

The pathways and their properties cannot be achieved by GME leaders alone. To be successful, a close partnership is needed between GME leadership and the highest level of executive leadership at a clinical site. This guidance document is a tool to help health care organizations prioritize and act upon opportunities to improve the CLE for resident and fellow physicians and—ultimately—patient care outcomes.

The ACGME News and Views section of JGME includes data reports, initiatives, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.