AccreditationCouncilfor
GraduateMedicalEducation
ClinicalLearningEnvironmentReview(CLER)
February 4-6, 2014, Interim LSU Hospital
Background
As a componentofitsnextaccreditationsystem, theACGMEhasestablished theCLERprogramtoassess the graduate medical education(GME)learningenvironmentof each sponsoringinstitutionandits participatingsites.Eachsponsoringinstitutionwill bevisitedevery 18months.
TheCLERvisitwillreviewinstitutionalactivities in theareasofsafety, qualityimprovement,transitions incare, supervision, dutyhoursoversight,fatiguemanagement/mitigation, andprofessional responsibilities.
Integrationof residentsintopatientsafetyprograms
Integrationof residentsintoQIandeffortstoreducedisparities
Establishment andimplementationofsupervisionpolicies
Oversightoftransitionsofcare
Oversightofdutyhours
Central CLER Questions
1. Whoandwhat form theinfrastructureofa SponsoringInstitution’s(SI)clinical learningenvironment?
2. HowintegratedistheGMEleadershipandfacultywithintheSI’s current
clinical learningenvironmentinfrastructure?
3. Howengaged aretheresidentsand fellows in usingtheSI’s current clinical
learningenvironment infrastructure?
4. HowdoestheSIdeterminethesuccessof itseffortstointegrateGMEinto the qualityinfrastructure?
5. What areas havetheSponsoringInstitutionidentifiedas opportunitiesfor
improvement?
This firstvisit focuseson questions1-3.
Questions 4-5 willbeusedin subsequent visits
Visit Framework
1. Initial meetingandExitmeetingwithseniorleadershipgroup(CEO, CMO,CNO,DIO)
2. Seriesof walk aroundvisitsin the hospital–senior resident servesastourescort
3. Separategroupmeetings with residencyprogramdirectors, corefaculty,andpeer-selected residents
4. Meetings withhospital’s chief qualityofficerand chiefsafetyofficer
Inthis initialvisitis,the findings willnotbeheld against the institution unlessan egregiousviolationis identified. TheACGME’sexampleof anegregious violationisaPGY-1startingalaparotomyin theORwithouta faculty memberpresent.
“How to Iprepare myfacultyand residents?”
Answer all questions honestlyandcompletely.Wewantanaccuratepictureof howwe’redoing.
Examples of Questions They May Ask:
PatientSafety
Howdoresidentsreporterrorsor nearmisses?
Doesthehospital provideasafe, non-punitiveenvironmentforreportingerrors,near missesandunsafe conditions?(askedofresidents,faculty, programdirectors,administrationandnursing)
Is reportingconsistentacross specialties?
Haveyoueverwitnessed anadverseevent,nearmiss,or unsafecondition? Did youreportit? Howdidyoureportit?
To the faculty: Howdoresidentsreportadverseevents, nearmisses,or unsafe conditions?
What happens tothosereports?
Areresidentsgiven feedback oncetheyreportanerror or nearmiss? Areresidentsinvolved inrootcauseanalyses?If so,how?
What happens toeventsdiscussed during M&Mconferences? Isthe informationtransferredtoa central repository?Dotheseconferenceslead toformal investigationsor systemanalyses?
Doesyour programadequatelyintegratethehospital’spatient safetypriorities,policies,andprocedures
intothecurriculum?
What arethehospital’s safetyprioritiesintheareaofpatient safety?
Quality Improvement
What arethehospitalgoalsfor quality?Aretheyaligned with national priorities? Areresidents/faculty/programdirectors awareofthesegoals?
Howareresidentsinvolvedin attainmentofthosegoals?
Areresidentsinvolved instrategicplanningormonitoringof theattainment ofthesegoals? Howdo youtrain your residentsandfellowsin qualityimprovement andpatientsafety?
Is thereastandardcurriculum?
Do your residentsfeel“ownership”of hospital QI processes?
Do your residentshaveaccesstoorganized systemsfor collectingandanalyzingdataforthepurposesof qualityimprovement?
Haveyouparticipated ina qualityimprovementproject?
Doestheorganizationmakeeffortstoaddresshealthcare disparities? Howarehealthcare disparitiesmeasured?
TransitionsofCare
Wheredoesthehospital believethereareissues related to transitionsof care?
Areresidents/facultyaware ofthese?
Howdoresidentsperformtransitionsofcare(handoffs)? Dotheyusea form? Acomputerizedtemplate?
Arehandoffsmonitored?If so,bywhom?Doeseachprogramutilizethesamesystem?
Supervision
Do youfeel thatyouareadequatelysupervised?
Do youfeel freetoaskforhelp whenyouareunsure? Is iteasyto reachouttoasupervisoratnight?
Do your supervisionpolicies allowfor advancementtowards independence?
Haveyoueverbeen placedin a situationwheretherewasinadequatesupervision?
Do youhaveanobjectivewayofknowingwhichproceduresa particular residentis allowedtoperform? Do you(resident)haveanobjectivewayof knowingwhetheranother resident is abletoperforma specificprocedure?
Howwouldanurseknowifyouarecredentialed todoaprocedureindependently?
Tonurses: Howwouldyou identifyaresident’s required levelof supervision?
DutyHours,FatigueManagementandMitigation
What doyouthinkof duty hour restrictions?
If youwerefatiguedwhileonthejob,whatwould youdo?
If you feltthatyoucouldn’tdriveyourself home,due tofatigue,whatwould youdo?
Aretherefacilitiesavailableforyoutonapif needed?
Is thecultureof your hospital responsivetoidentifyingandmanagingfatigue? Howwereyoueducatedaboutfatigue?
Professionalism
Do youreceiveeducation aboutprofessionalism?
Doesyour hospital providea supportive,non-punitiveenvironmentfor bringingforwardconcerns regardinghonestyin reporting?
Haveyoueverfeltpressuredtocompromiseyour integritytosatisfyan authorityfigure?
Scenario: Anattendingmistreatsacolleague.Howwould youadvisethecolleague?What ifthe colleaguewasuncomfortable goingthroughtheGMEchainofcommand?
Haveyoueverdocumented ahistoryor physical findingthatyou didn’tpersonallyelicit?
Do youhaveaccesstounpublishedboardreviewquestions? Do youaccuratelyreport your dutyhours?