The ACGME's mission is to improve health care and population health by assessing and advancing the quality of residents and fellows' education through accreditation.1 Over the past few years it has become readily apparent the clinical setting in which residents and fellows learn directly impacts the quality of their training. In order to better understand these environments, the ACGME established the Clinical Learning Environment Review (CLER) Program in 2012.2,3 The CLER Program is linked to accreditation only in that every institution must periodically complete a visit.

The CLER Program focuses on the hospitals, medical centers, and ambulatory care practices where residents and fellows train. Research has shown that young physicians' experience in these institutions shapes the care they deliver for years afterward.4,5 For that reason, the CLER Program refers to such sites collectively as the clinical learning environment (CLE), a name that underscores their educational significance. In this report, the term CLE means any and all such clinical settings where residents and fellows learn to care for patients. The CLE is much more than a set of places and resources. It also includes the people, their values, and the sense of dedication to team and community.

The CLER Program is designed to provide formative feedback that presents graduate medical education (GME) leaders and the executive leadership of the CLE sites with information on six areas of focus: patient safety, health care quality, care transitions, supervision, duty hours/fatigue management and mitigation, and professionalism. Concentrating on these areas helps to ensure that CLEs embrace a culture of continuous improvement and produce physicians who are committed to systems-based improvements in patient safety and health care quality throughout their professional lives.

The underlying premise of the CLER Program is that when GME leaders and executive leadership of CLEs are presented with detailed information on how they are addressing the six focus areas, they will use it to build upon their strengths and identify and act on opportunities for improvement—with the ultimate goal of improving patient care while optimizing the educational experience for resident and fellow physician learners.

Five Key Questions
  1. What is the clinical learning environment's infrastructure for addressing the six focus areas?

  2. How integrated is the GME leadership and faculty within this infrastructure?

  3. How engaged are the resident and fellow physicians in working with the clinical learning environment's infrastructure to address the six focus areas?

  4. How does the clinical learning environment determine the success of its efforts to integrate GME into its infrastructure?

  5. What areas has the clinical learning environment identified as opportunities for improvement?

Based on a model that promotes continuous quality improvement, the CLER Program conducts periodic site visits. The site visits are structured to gather evidence that will help answer the five key questions shown above. In the first set of visits, the CLER Program sought to establish a baseline, and—for that reason—focused principally on the first three questions, which address the infrastructure that CLEs have in place for each of the six focus areas and how residents, fellows, and faculty members engage in that infrastructure.

The site visits are the core of the CLER Program.2,3 Essential to the visits are initial and exit interviews that include the GME leadership of the Sponsoring Institution (SI) and the executive leadership of the CLE (e.g., Chief Executive Officer, Chief Medical Officer, and other members of executive management) as well as structured interviews with the CLE's leaders in patient safety and health care quality, residents, fellows, faculty members, and program directors.

The CLER team also conducts walking rounds of a number of clinical areas (e.g., clinical inpatient and outpatient areas, perioperative areas, intensive care, emergency departments)—using this opportunity to interact with residents, fellows, faculty members, nurses, and other health care professionals.

At the conclusion of the CLER visit, the leaders of GME and executive leaders of the CLE receive an oral report that synthesizes the team's findings in the six focus areas—followed by a written report. The findings in the reports do not influence the accreditation status of the SI or its programs. Rather, the reports provide individual CLEs with observations and information that can be used at their discretion to improve resident and fellow training and promote continuous improvement in the CLE.

In parallel with establishing the CLER site visit program, the ACGME also formed a CLER Evaluation Committee for the purpose of providing oversight and guidance. The CLER Evaluation Committee is made up of experts in a broad range of relevant subjects—including those with experience in GME, health care administration, patient safety, health care quality, and other aspects of the six focus areas—as well as resident members and representatives of the public.

As the oversight body for CLER, the Evaluation Committee is charged with setting expectations for the six focus areas and providing institutions with national aggregated data from the site visits to help guide improvements in the CLE.

The Evaluation Committee began work in the fall of 2012 and helped formulate the protocol used in this first set of visits. Early on, the members of the Committee recognized an opportunity to provide the GME community, teaching hospitals and medical centers, and the public with guidance on optimizing the CLE. The Committee devoted much of its first year to sharing expertise, gathering input from various key stakeholders, and reviewing the qualitative findings from the first 100+ CLER visits. The committee members then developed the CLER Pathways to Excellence6 as a publically available resource with the goal of improving GME training while also improving patient care.7,8 

The Pathways document outlines a series of expectations for optimizing the CLE across the six focus areas. For each area, the document defines multiple pathways and numerous properties for each pathway.

This report presents findings from the first set of CLER site visits to participating sites of 297 ACGME-accredited SIs of residency and fellowship programs. These visits, conducted from September 2012 through March 2015, focused primarily on teaching hospitals, medical centers, and ambulatory sites that host three or more core residency programs. The CLER Program elected to begin with these larger SIs so as to gather information on the sites that affect the majority of residents and fellows in training. First time visits to the rest of the SI community—approximately 400 ACGME-accredited SIs that have two or fewer core residency programs each—began in September 2015 and will take approximately three years to complete. These visits encompass many rural and safety-net sites for clinical care. The results from visits to the smaller SIs will be published separately later.

The findings from the larger SIs are presented in this report from several different perspectives, ranging from broad-based overarching themes to detailed descriptions for each of the six focus areas. The appendices include a number of technical tables and figures.

The section on overarching themes9 presents broad, high-level observations that cut across the six CLER focus areas and comments on issues related to infrastructure, alignment of leadership, and strategic use of resources. The section on challenges and opportunities10 highlights three to five key findings within each focus area and provides commentary on their potential impact on GME and patient care. The section on detailed findings11 presents a more comprehensive look at the CLER data in both narrative and graphic form. This section includes the findings highlighted in the section on challenges and opportunities, as well as additional data for each focus area. The report concludes with a section on some of the noteworthy lessons learned12 and a preview of future directions for the ACGME and the CLER Program.

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Author notes

CLER Program: Mark Bixby, MD; Baretta R. Casey, MD, MPH, FAAFP; Robin Dibner, MD; Anne Down; Staci Fischer, MD; Constance Haan, MD, MS, MA; Scott A. Holliday, MD*; Elizabeth Kimball, MA; Nancy J. Koh, PhD; Robin Newton, MD, FACP; Carl Patow, MD, MPH, FACS*; Mark Pian, MD*; Dale Ray, MD, MMM; Melissa Schori, MD, FACP, MBA; Robin Wagner, RN, MHSA; Elizabeth Wedemeyer, MD, FAAP; Kevin B. Weiss, MD

* Former staff member