Get a “CLEW”: Using Clinical Learning Environment Walks (CLEWs) to Optimize Clinical Learning Environments Open Access

Leadership rounding, or “gemba walks,” are well described in the safety literature as an effective means to communicate the importance of the hospital's improvement agenda, to gain clearer understanding of safety issues, and to build rapport with frontline caregivers. Talking with caregivers at the bedside has long been an important part of environmental assessments performed by agencies, such as The Joint Commission and, more recently, the Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) site visitors. Designated institutional officials, program directors, and others in graduate medical education (GME) leadership have a significant stake in the health of the “actual” culture in which residents engage. GME leaders have historically relied on resident surveys, patient safety reports, other inquiries (eg, risk management), and more recently CLER survey reports, to inform their perspective on the learning environment.

The clinical learning environment walks (CLEWs) are built on the concept of gemba walks, but focus more explicitly on assessing the 6 focus areas in the CLER Pathways to Excellence: patient safety, health care quality, care transitions, supervision, duty hours/fatigue management and mitigation, and professionalism. CLEWs consist of unannounced visits to hospital units, using a questionnaire to guide discussions with residents and nursing staff.

Over the last 2 years, the San Antonio Uniformed Services Health Education Consortium (SAUSHEC) developed a CLEW questionnaire utilizing specific and open-ended questions to get a sense of the culture of resident engagement within these working environments (provided as online supplemental material). The designated institutional official, assistant dean of quality improvement and patient safety, and program directors conduct monthly CLEWs in tandem or alone. A hospital unit is selected for a CLEW to assess or to better understand issues identified via an institutional survey, the ACGME CLER report, or reported patient safety events. CLEWs are also used to assess implementation and impact of improvement initiatives. The GME office maintains a spreadsheet to track dates of hospital unit CLEWs, issues identified, and, if warranted, action plans to address concerns.

All who have conducted CLEWs have reported they are well received on the units. Each visit (including completion of a CLER-focused questionnaire) takes approximately 30 minutes. More than 20 CLEWs have been conducted to verify successful and unsuccessful implementation of GME-focused patient safety initiatives within the hospital, as shown in 2 examples. First, after an adverse event, a CLEW by the SAUSHEC Supervision Subcommittee verified successful implementation and nursing understanding of a new resident procedural verification policy. Second, a colored badge system distinguishing medical students, residents, and faculty, resulting from a GME/hospital collaborative, was highly praised during The Joint Commission visit. However, several CLEWs demonstrated that nursing staff often were not fully aware of the badge system. This led to a meeting between GME and nursing leadership to develop a systematic process to ensure better communication of all GME-centered patient safety initiatives moving forward.

CLEW findings have also resulted in resident-led quality improvement projects, improved interdisciplinary rounding, and enhanced adverse event reporting. After the CLEW concept was presented at a national meeting of GME institutional leaders, a significant proportion of the participants reported the process would be “very useful” (35%) or “useful” (38%) at their institution. The University of Texas Health Science Center at San Antonio subsequently implemented CLEWs successfully in a setting where the sponsoring institution does not own the participating site. The University of Texas Health Science Center at San Antonio GME and hospital leaders partner on walks, increasing the level of teamwork between the sponsoring institution and participating site while promoting enhanced communication and transparency. In both institutions' experiences, CLEWs have been effective in assessing the learning environment and validating the impact of improvement initiatives.

CLEWs based on a templated questionnaire around the 6 CLER focus areas provide a better understanding of the learning environment to aid institutions along the ACGME CLER Pathways to Excellence.