Clinical Learning Environment Review (CLER)

In 2014, the ACGME continued with its transition to outcomes-based assessment of Sponsoring Institutions and their affiliated hospitals to include a new initiative -- the Clinical Learning Environment Review (CLER).  GME leaders and the ACGME agreed that 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 CLER Program.  It involves the assessment of your Sponsoring Institution and its affiliated hospitals in providing an optimal educational experience in an environment that delivers safe, quality medical care.  

The CLER Program has been designed to provide graduate medical education (GME) leaders of Sponsoring Institutions and the executive leadership of clinical learning environments ( i.e., hospitals) with formative feedback on six areas of focus below.  CLER data is not being used in accreditation decisions by the Institutional Review Committee (IRC).  The ACGME’s goal is to ensure that Residents and Fellows are key participants in these six focus areas and that Residents and Fellows work hand-in-hand to safeguard and improve these areas.  

CLER assesses Sponsoring Institutions in the following six focus areas:

• Patient Safety – including opportunities for Residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care. 
• Healthcare Quality (QI)  – including how sponsoring institutions engage Residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes
• Teaming (to promote safe and efficient Transitions in Care) – including how sponsoring institutions demonstrate effective standardization and oversight of transitions of care and supporting high-performance teaming. The concept of teaming recognizes need for purposeful interactions in which team members coordinate safe and efficient care, collaborating and sharing accountability. 
• Supervision – including how sponsoring institutions maintain and oversee policies of supervision concordant with ACGME requirements in an environment at both the institutional and program level that assures the absence of retribution. 
• Well-Being – The optimal clinical learning environment is engaged in systematic and institutional strategies and processes to cultivate and sustain the well-being of both its patients and clinical care team.  The original focus area was called “Duty Hours, Fatigue Management, & Mitigation” but has evolved into “Well-Being,” addressing four interrelated topics:  work and life balance; fatigue; burnout; and support of those at risk or demonstrating self-harm.  This new focus area recognizes the important role of clinical learning environments in designing and implementing systems that monitor and support physician well-being.
• Professionalism—with regard to how sponsoring institutions educate for professionalism, monitor behavior on the part of Residents and faculty and respond to issues concerning: accurate reporting of program information;  integrity in fulfilling educational and professional responsibilities; and veracity in scholarly pursuits. 

The CLER Site Visit Program is used solely for providing feedback, learning, and helping to establish baselines for sponsoring institutions, the Evaluation Committee, and the IRC. The underlying premise of the CLER Program is that when GME leaders and the executive leadership of the Clinical Learning Environments 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.  Hopefully, institutions will be more aware of the importance of taking a systems-based approach to improving the Clinical Learning Environment. The CLER Program will continue to explore how best to address these variations in order to promote excellence in the Clinical Learning Environment and advance patient care.

CLER visits are structured to gather evidence that will help answer five key questions:

• What is the clinical learning environment’s infrastructure for addressing the six focus areas? What organizational structures and administrative and clinical processes do the Sponsoring Institution and its major participating sites have in place to support GME learning in each of the six focus areas?
• How integrated is the GME leadership and faculty within this infrastructure? What is the role of GME leadership and faculty to support Resident and Fellow learning in each of the six areas?
• How engaged are the resident and fellow physicians in working with the clinical learning environment’s infrastructure to address the six focus areas?   How comprehensive is the involvement of Residents and Fellows in using these structures and processes to support their learning in each of the six areas? 
• How does the clinical learning environment determine the success of its efforts to integrate GME into its infrastructure?  From the perspective of the Sponsoring Institutions and its teaching hospitals, what are the measures of success in using this infrastructure and what was the level of success? 
• What areas has the clinical learning environment identified as opportunities for improvement?  From the perspective of the Sponsoring Institution and its teaching hospitals, what are seen as the opportunities for improving the quality and value of the current clinical learning environment infrastructure to support the six focus areas?

As Residents and Fellows in our GME Programs, you might even be asked to host the CLER Team on their “walking rounds” to various clinical areas they choose important in the hospital, including the Emergency Department, operating rooms, critical care units, labor and delivery, and even Resident call quarters.  Most importantly, you will be an active participant throughout your training in improving the safety and quality of your care to your patients with the advent of the CLER Initiative.

The ACGME has dictated that CLER visits would occur every 18 -24 months.   The UT College of Medicine Chattanooga and Erlanger has participated in three CLER visit (2014, 2016, and 2018).  Our fourth CLER visit would have occurred after May 2020; however, due to the COVID-19 pandemic, all site visits, including CLER visits were postponed in March, 2020.  ACGME Institutional and program accreditation visits have begun being conducted remotely (primarily via Zoom or similar technology).  The ACGME is considering remote CLER visits to assess the impact of the pandemic on institutions and trainees across our country and even internationally.  The ACGME Annual Web Ads Update process that began in August added several COVID-19 specific questions to begin obtaining that information.  We anticipate a remote CLER review in 2021.

On December 2, 2019, the Accreditation Council for Graduate Medical Education’s (ACGME’s) Clinical Learning Environment Review (CLER) Program announced the publication of CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, Version 2.0. The CLER pathways, organized according to the six CLER Focus Areas of Patient Safety, Health Care Quality, Teaming, Supervision, Well-being, and Professionalism, serve as a tool to promote discussions and actions to optimize the clinical learning environment.  Click on this link to review the electronic publication:  CLER Pathways to Excellence

Most recently, in a request from the Ways and Means Committee of the United States House of Representatives, Dr. Nasca answered this question asked by the Committee Chair, the Honorable Richard Neal (September 25, 2020):

"Please update the Committee on the ACGME’s efforts to educate its staff and raise awareness about health inequities affecting Black, Latina, Indigenous, and other communities of color. How is the ACGME supporting racial and ethnic diversity of leading voices in the discussions and strategy development relating to health equity education as it relates to medical training and accreditation?"

ACGME Response:

"The ACGME is integrating discussion about approaches to diversity, equity, and inclusion in its Clinical Learning Environment Review (CLER) Program, which is designed to provide U.S. teaching hospitals, medical centers, health systems, and other clinical settings affiliated with ACGME-accredited Sponsoring Institutions with periodic feedback that addresses the following six Focus Areas: Patient Safety; Health Care Quality; Care Transitions; Supervision; Well-Being; and Professionalism. Feedback from the CLER Program is designed to improve how clinical sites engage resident and fellow physicians in learning to provide safe, high quality patient care. Through interviews with leaders of the above-mentioned organizations, the CLER Program now assesses organizations’ systemic approach to eliminating health disparities in their clinical learning environments. Already, the ACGME has observed progress. In the past three rounds of national reviews, fewer than four percent of CEO's had a systematic plan to eliminate health care disparities. In the last review cycle, however, nearly 25 percent of CEO's had or were developing approaches to eliminate health care disparities in their institutions. The ACGME will continue to encourage and support this encouraging progress, a positive inflection point consistent with the ACGME’s view that health disparities are a quality issue that necessitate intentional, ongoing work to eliminate them and improve the quality of health care for all."