Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.

The Accreditation Council for Graduate Medical Education (ACGME) recognizes the public's need for a physician workforce capable of meeting the challenges of a rapidly evolving health care environment. The ACGME has responded to this need by implementing the Clinical Learning Environment Review (CLER) program as a part of its Next Accreditation System. The CLER program is designed to provide US teaching hospitals, medical centers, health systems, and other clinical settings affiliated with ACGME-accredited institutions with periodic feedback that addresses the following 6 areas: patient safety, health care quality, transitions in care, supervision, duty hours and fatigue management and mitigation, and professionalism. The feedback provided by the CLER program is designed to improve how these clinical sites engage physician trainees in learning to provide safe, high-quality patient care.

To further the aim of the CLER program, the ACGME has developed the CLER Pathways to Excellence as a tool to promote discussions and actions that will optimize the clinical learning environment. The CLER pathways are designed as expectations rather than requirements. It is anticipated that by setting these expectations, clinical sites that provide training will strive to meet or exceed them in their efforts to provide the best care to patients and train the highest-quality physician workforce.

Patient Safety

PS Pathway 1: Reporting of adverse events, close calls (near misses)

PS Pathway 2: Education on patient safety

PS Pathway 3: Culture of safety

PS Pathway 4: Resident/fellow experience in patient safety investigations and follow-up

PS Pathway 5: Clinical site monitoring of resident/fellow engagement in patient safety

PS Pathway 6: Clinical site monitoring of faculty member engagement in patient safety

PS Pathway 7: Resident/fellow education and experience in disclosure of events

Health Care Quality

HQ Pathway 1: Education on quality improvement

HQ Pathway 2: Resident/fellow engagement in quality improvement activities

HQ Pathway 3: Residents/fellows receive data on quality metrics

HQ Pathway 4: Resident/fellow engagement in planning for quality improvement

HQ Pathway 5: Resident/fellow and faculty member education on reducing health care disparities

HQ Pathway 6: Resident/fellow engagement in clinical site initiatives to address health care disparities

Care Transitions

CT Pathway 1: Education on care transitions

CT Pathway 2: Resident/fellow engagement in change of duty handoffs

CT Pathway 3: Resident/fellow and faculty member engagement in patient transfers between services and locations

CT Pathway 4: Faculty member engagement in assessing resident-related patient transitions of care

CT Pathway 5: Resident/fellow and faculty member engagement in communication between primary and consulting teams

CT Pathway 6: Clinical site monitoring of care transitions

Supervision

S Pathway 1: Education on supervision

S Pathway 2: Resident/fellow perception of the adequacy of supervision

S Pathway 3: Faculty member perception of the adequacy of resident/fellow supervision

S Pathway 4: Roles of clinical staff other than physicians in resident/fellow

S Pathway 5: Patients and families and graduate medical education supervision

S Pathway 6: Clinical site monitoring of resident/fellow supervision and workload

Duty Hours/Fatigue Management and Mitigation

DF Pathway 1: Culture of honesty in reporting of duty hours

DF Pathway 2: Resident/fellow and faculty member education on fatigue and burnout

DF Pathway 3: Resident/fellow engagement in fatigue management and mitigation

DF Pathway 4: Faculty member engagement in fatigue management and mitigation

DF Pathway 5: Clinical site monitoring of fatigue and burnout

Professionalism (Selected Topics)

PR Pathway 1: Resident/fellow and faculty member education on professionalism

PR Pathway 2: Resident/fellow attitudes, beliefs, and skills related to professionalism

PR Pathway 3: Faculty engagement in training on professionalism

PR Pathway 4: Clinical site monitoring of professionalism

Selected Readings

Selected Readings
Armstrong
A
,
Headrick
L
,
Madigosky
W
,
Ogrinc
G
.
Designing education to improve care
.
Jt Comm J Qual Patient Saf
.
2012
;
38
(
1
):
5
14
.
Arora
V
,
Johnson
J
.
A model for building a standardized hand-off protocol
.
Jt Comm J Qual Patient Saf
.
2006
;
32
(
11
):
646
655
.
Bagian
JP
.
Patient safety: what is really at issue
?
Front Health Serv Manage
.
2005
;
22
(
1
):
3
16
.

Author notes

Kevin B. Weiss, MD, MPH, is Senior Vice President, Institutional Accreditation, and Co-Chair, Clinical Learning Environment Review (CLER) Evaluation Committee, Accreditation Council for Graduate Medical Education (ACGME); James P. Bagian, MD, is Professor of Anesthesiology and Industrial and Operations Engineering, University of Michigan, and Co-Chair, CLER Evaluation Committee, ACGME; and Robin Wagner, RN, MHSA, is Vice President, CLER, ACGME.

The Clinical Learning Environment Review Pathways to Excellence is reprinted with permission from the Accreditation Council for Graduate Medical Education.