The CLER Pursuing Excellence Pathway Leaders Collaborative: Enhancing Resident and Fellow Engagement in Patient Safety

Earlier this year, the Accreditation Council for Graduate Medical Education (ACGME) Pursuing Excellence in Clinical Learning Environments initiative wrapped up an 18-month national learning collaborative focused on engaging residents and fellows in patient safety. The collaborative was the first in the Pursuing Excellence Pathway Leaders collaborative series, which brings together teams from ACGME-accredited sponsoring institutions (SIs) to identify new structures and processes for optimizing the clinical learning environment (CLE) in one or more of the Clinical Learning Environment Review (CLER) Focus Areas.¹ Pursuing Excellence and each of its collaboratives are designed to foster a community where SIs learn from each other and work together to address opportunities identified through the CLER Program's formative site visit process.^2–4 By sharing the experiences of the Pursuing Excellence teams in this article and in reports to follow, the CLER Program is promoting ongoing national conversations on how to enhance resident and fellow training in the context of delivering patient care.

The Teams

The Pathway Leaders Patient Safety Collaborative began in June 2017 with a request for applications from SIs committed to enhancing their CLE's ability to engage residents and fellows in systems-based approaches to improving patient safety. Of the 18 SIs that applied, 9 were selected to participate in the collaborative:

• Carolinas Medical Center

• Duke University Hospital

• Indiana University School of Medicine

• Maimonides Medical Center

• St. Vincent's East Family Medicine

• University of Connecticut School of Medicine

• University of Kentucky College of Medicine

• University of Nevada, Reno School of Medicine

• University of Pennsylvania Health System

The teams represented a diverse set of SIs, with as few as 18 to as many as 1068 residents and fellows and from 1 to more than 70 residency and fellowship programs.

Building From a National Framework

To guide their work, the Patient Safety Collaborative teams built on a framework developed by the National Collaborative for Improving the Clinical Learning Environment (NCICLE) for engaging new clinicians in patient safety.⁵ The NCICLE framework includes 4 areas in which new clinicians need to attain competence by the end of their first year in practice: (1) Understand the CLE's “culture of safety”; (2) Recognize and report patient safety issues; (3) Participate in the analysis of patient safety events; and (4) Recognize how the CLE translates patient safety event reports into improvements.

In this framework,⁵ NCICLE emphasizes the need for CLEs to keep a systems lens as they develop organizational strategies for engaging new clinicians in patient safety. The success of engaging new clinicians in their first year within a new CLE depends on leadership ensuring that the organization's policies, infrastructure, and processes support learner engagement. These resources may include dedicated time for training and learning, organized systems for reporting and analyzing patient safety events, and methods for communicating process changes and lessons learned. NCICLE also notes that CLEs committed to improving patient safety routinely monitor their processes and outcomes to build on successes and address needed improvements.

Key Components of the Patient Safety Collaborative

With the NCICLE framework as the foundation, Patient Safety Collaborative faculty members developed activities and tools to fit the goals and time frame of the collaborative. Perhaps the most innovative element of the Pathway Leaders Patient Safety Collaborative was the decision to focus on engaging residents and fellows in analyzing patient safety events—rather than reporting events. The collaborative's faculty recognized that patient safety event analysis had the greatest potential to inspire learners, create change in the organizational patient safety culture, and ultimately improve patient care. With this focus on event analysis, the collaborative worked to address the following questions.

When in the First Year Is the Best Time to Engage Residents and Fellows to Instill These Behaviors?

To inspire resident and fellow engagement and to develop their skills in patient safety practices, the teams were tasked with engaging all first-year residents and fellows in their SI with real event analysis experiences. Some of the collaborative teams approached this task by starting with experiential learning within the first month of the first year, and others started later in the first year. All had the goal of getting 100% of their new learners engaged within the first 12 months of coming to that clinical site.

How Does the CLE Best Shape These Behaviors?

The collaborative set the following expectations for providing residents and fellows with a meaningful experience in patient safety event analysis:

• The experience needed to be based on a recent (within 30 days) patient safety event.

• The residents and fellows needed to participate in all aspects of the event analysis (including initial discovery, structured analysis/root cause analysis, and development of action plans).

• The analysis experience needed to include other professions and staff relevant to the event.

• The approach to assessment needed to be structured and robust to ensure the event analysis provided meaningful recommendations for improvement.

To fulfill these expectations, teams needed their CLE to assist graduate medical education (GME) leadership in developing and implementing new processes to access current event reports (within 30 days) and to facilitate inclusion of interprofessional staff as part of the analysis team.

Who Needs to Be Involved?

Executive leadership, patient safety leadership, and GME leadership all had essential roles in supporting this new approach to engage residents and fellows in improving patient safety. In particular, partnerships between the CLE's clinical education leaders and patient safety leaders were important for ensuring the integration of clinical training with the institution's patient safety initiatives.

Team Experiences

Before joining the collaborative, teams were inconsistent in how they engaged residents and fellows in patient safety event analysis. The degree of resident engagement often varied from program to program and lacked a system of accountability for the quality of the learning or the integration with the CLE's infrastructure for addressing patient safety.

Over the 18 months of the collaborative, the participating teams steadily began to evolve from a GME-oriented approach to engaging residents and fellows in patient safety to a CLE-oriented approach in which residents and fellows learned new skills and contributed to systems-based solutions to improving patient care. As part of this evolution, each team had to develop the skills to become co-developmental partners (GME-CLE) with the shared goal of creating meaningful experiences that provide value for both learners and patient care.

In reflecting on their experience, the Pathway Leaders Patient Safety Collaborative teams have noted the importance of intentionally investing time to jointly establish processes that the CLE and GME together can use to continually and actively involve residents and fellows in addressing patient safety—such that residents and fellows are recognized and sought out for the valuable perspectives they bring as frontline providers of care. Furthermore, teams acknowledged that reframing learning to begin with patient safety event analysis has successfully contributed to culture change within their CLEs.

Future Directions

This fall, Pursuing Excellence will be offering the opportunity for the Patient Safety Collaborative teams to continue the work they have done in this initial collaborative in a new Advanced Patient Safety Collaborative. Almost all of the initial teams have committed to another 18 months of advancing work in this important area. In addition, Pursuing Excellence will be engaging a second cohort of Pathway Leaders Patient Safety Collaborative teams. This second cohort will begin their work in fall 2019 and will have the first cohort of Patient Safety Collaborative teams as mentors.

The CLER Program looks forward to reporting on the important learning and successes of these teams. Information on the Advanced Patient Safety Collaborative and the second Pathway Leaders Patient Safety Collaborative is available at https://www.acgme.org/what-we-do/initiatives/pursuing-excellence/overview. A full report describing the Patient Safety Collaborative program, tools, and team experiences will be released in 2020.