Introducing the CLER Pathways to Excellence: A New Way of Viewing Clinical Learning Environments

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.

In January 2014, the Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) program released “CLER Pathways to Excellence: expectations for an optimal clinical learning environment to achieve safe and high-quality patient care” as guidance for the GME community, hospitals, medical centers, clinics, and other organizations that serve as sites for physician residency and fellowship programs.^1,2 To launch this new resource, the ACGME held a conference “Preparing Doctors for 21st Century Practice” on January 27, 2014, at the Barbara Jordan Conference Center of the Kaiser Family Foundation in Washington, DC, and invited a variety of stakeholders from national health care organizations, graduate medical education (GME), and the media.

The launch event focused attention on the clinical settings (inpatient hospitals and ambulatory clinics) where resident and fellow physicians learn to deliver patient care. Thomas Nasca, MD, MACP, chief executive officer, ACGME, opened the event with remarks that emphasized the clinical learning environment as an essential component to GME.³ Dr Nasca noted, “In the past decade there has been only modest progress in improving patient safety. Physicians need to be encouraged to interact more with hospitals, medical centers, and ambulatory sites to effect lasting improvements in patient care. It is critical to engage residents and fellows early in their careers as studies show there is a direct link between a physician's performance in initial training and their clinical performance throughout their lifetime of practice.”

John Duval, chief executive officer of Virginia Commonwealth University, provided the perspective of health care organizations and spoke to the value of enhancing resident and fellow physician involvement in efforts to improve care. The conference also included panel discussions moderated by Susan Dentzer, MA, senior policy adviser, Robert Wood Johnson Foundation, which further examined opportunities and challenges to enhancing GME engagement in patient safety and health care quality.

In the final keynote, Kevin Weiss, MD, MPH, senior vice president, Institutional Accreditation, ACGME, and James P. Bagian, MD, director, Center for Health Engineering and Patient Safety, University of Michigan, highlighted the development and release of the CLER Pathways to Excellence. In his remarks, Dr Bagian emphasized that “this new document should be used as a tool to effect improvements in patient safety and health care quality for all health care organizations not only those that train physicians.”

The text that follows is adapted from the introduction to the CLER Pathways to Excellence.

CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care

In the late 1990s, the Institute of Medicine conducted a multiyear project to examine the quality of health care in the United States.⁴ The result of that effort was a series of reports that highlighted serious patient safety concerns, variability in the quality of care, and continuing health care disparities. More than 10 years after the release of those reports, there has been little evidence to suggest any dramatic improvement in the nation's health care.

The physician workforce is one of the key levers to improving health care. A survey of hospital leaders conducted by the American Hospital Association found that newly trained physicians were deficient in the areas of communication, use of systems-based practices, and interprofessional teamwork, and highlighted the need to educate US physicians, residents, and fellows to address quality improvement.⁵

There are more than 117 000 resident and fellow physicians in US teaching hospitals and medical centers, and they work on the front line of care. In this role they need to be prepared to recognize patient safety events and intervene as appropriate, champion performance improvement efforts, and work effectively in interprofessional teams to develop and apply systems-based solutions to such issues as transitions in patient care. This next generation of physicians needs the skills to be able to lead changes in our nation's health care organizations, both large and small.

ACGME recognizes the public's need for a physician workforce capable of meeting the requirements of a rapidly evolving health care environment.

Developing the CLER Pathways to Excellence

The CLER Pathways to Excellence emerged from early experience with the CLER program.^6,7 This document was developed by the ACGME's CLER Evaluation Committee, a group that provides oversight and guidance on all aspects of CLER program development, with input from selected published literature, CLER field staff site visit experience, and several focus groups across the country.

In keeping with the CLER program's foundation of continuous quality improvement, the CLER Pathways to Excellence will evolve over time based on what is learned from the data generated by the CLER site visits as well as from continued input from GME leadership, the executive leadership of ACGME-accredited teaching hospitals and other clinical sites, and the community.

Using the CLER Pathways' Framework

The CLER Pathways to Excellence highlights the importance of 3 distinct groups of professionals in the education of our future physician workforce: faculty members, nurses, and executive leadership. Because faculty members serve an important mentoring role, many of the pathways highlight ways in which faculty members can model optimal behavior in addressing the CLER focus areas. Many of the pathways also stress the importance of interprofessional teams—in particular nurse-physician collaborations—in addressing the 6 focus areas. Finally, most of the pathways and their properties cannot be achieved without a close partnership between the GME leadership and the highest level of executive leadership at the clinical site. The clinical environment must model in everyday practice the various properties that constitute the 6 focus areas.

The CLER Pathways to Excellence is designed to provide a framework for clinical sites to use in their continuing efforts to prepare physicians—residents and faculty—to deliver consistently safe, high-quality patient care.

Achieving Success

The CLER Evaluation Committee, and ultimately the ACGME Board of Directors, will continually monitor the progress of the CLER program. Success associated with the CLER Pathways to Excellence will be assessed by tracking aggregated data over time and mapping the forward progress along each pathway toward the goal of achieving optimal engagement.

The ACGME anticipates that this new framework for evaluating the clinical learning environment will lead to enhanced interest, experimentation, and innovation in this important aspect of GME. The CLER Pathways to Excellence is intended to accelerate action on a national basis by educators, health care leadership, policy makers, and patient advocates to continually assess and improve the environments in which the US physician workforce is educated as well as the effectiveness of GME in promoting safe, high-quality patient care.