CLER Pathways to Excellence, Version 2.0: Executive Summary

The Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) Program is pleased to announce the publication of version 2.0 of CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care.¹ The CLER Pathways, organized according to the 6 CLER Focus Areas (Table), serve as a tool to promote discussions and actions to optimize the clinical learning environment. The ACGME presents the CLER pathways as expectations rather than requirements, anticipating that clinical learning environments will strive to meet or exceed these expectations in their efforts to provide the best care to patients and to produce the highest quality physician workforce.

Table.

CLER Pathways to Excellence^a

CLER Focus Area	Pathways
Patient Safety	1. Education on patient safety 2. Culture of safety 3. Reporting of adverse events, near misses/close calls, and unsafe conditions 4. Experience in patient safety event investigations and follow-up 5. Clinical site monitoring of resident, fellow, and faculty member engagement in patient safety 6. Resident and fellow education and experience in disclosure of events 7. Resident, fellow, and faculty member engagement in care transitions
Health Care Quality	1. Education on quality improvement 2. Resident and fellow engagement in quality improvement activities 3. Data on quality metrics 4. Resident and fellow engagement in the clinical site's quality improvement planning process 5. Resident, fellow, and faculty member education on eliminating health care disparities 6. Resident, fellow, and faculty member engagement in clinical site initiatives to eliminate health care disparities 7. Residents, fellows, and faculty members deliver care that demonstrates cultural humility
Teaming	1. Clinical learning environment promotes teaming as an essential part of interprofessional learning and development 2. Clinical learning environment demonstrates high-performance teaming 3. Clinical learning environment engages patientsb to achieve high-performance teaming 4. Clinical learning environment maintains the necessary system supports to ensure high-performance teaming
Supervision	1. Education on supervision 2. Culture of supervision 3. Roles of clinical staff members other than physicians in resident and fellow supervision 4. Patientb perspectives on graduate medical education supervision 5. Clinical site monitoring of resident and fellow supervision and workload
Well-Being (selected topics)	1. Clinical learning environment promotes well-being across the clinical care team to ensure safe and high-quality patient care 2. Clinical learning environment demonstrates specific efforts to promote the well-being of residents, fellows, and faculty members 3. Clinical learning environment promotes an environment where residents, fellows, and faculty members can maintain their personal well-being while fulfilling their professional obligations 4. Clinical learning environment demonstrates system-based actions for preventing, eliminating, or mitigating impediments to the well-being of residents, fellows, and faculty members 5. Clinical learning environment demonstrates mechanisms for identification, early intervention, and ongoing support of residents, fellows, and faculty members who are at risk of or demonstrating self-harm 6. Clinical learning environment monitors its effectiveness at achieving the well-being of the clinical care team
Professionalism (selected topics)	1. Education on professionalism 2. Culture of professionalism 3. Conflicts of interest 4. Patientb perceptions of professional care 5. Clinical site monitoring of professionalism

^aThis Table lists the CLER pathways only. Readers should refer to the full CLER Pathways to Excellence¹ for the properties associated with each of the pathways.

^b“Patient” can include family members, caregivers, patient legal representatives, and others.

The CLER Pathways to Excellence is designed to continuously evolve, keeping up with the needs of dynamic clinical learning environments. The ACGME's CLER Evaluation Committee, a group that provides oversight and guidance on all aspects of the CLER Program, periodically reviews cumulative data from the CLER site visits, along with emerging research in the 6 Focus Areas, and uses the information to reassess the pathways, revise them as needed, and make recommendations, as appropriate, regarding potential changes to graduate medical education accreditation requirements. As elements of the CLER Pathways to Excellence migrate to the requirements, these elements are removed from future versions of the document and replaced with new areas for exploration. In this manner, the CLER Program serves as a catalyst to continually inform accreditation, while striving for excellence in patient safety and health care quality.

In keeping with this evolution, version 2.0 of the CLER Pathways to Excellence differs from previous versions in that it frames each of the pathways and their associated properties from the health system's perspective. This change recognizes that health care organizations create, and therefore are primarily responsible for, the clinical learning environment. It also emphasizes the importance of the interface between graduate medical education and the hospitals, medical centers, and ambulatory sites that serve as clinical learning environments.

This version also introduces the new CLER Focus Area called “Teaming.” The concept of teaming recognizes the dynamic and fluid nature of the many individuals who come together in the course of providing patient care to achieve a common vision and goals. Teaming recognizes the benefits of purposeful interactions in which team members quickly identify and capitalize on their various professional strengths—coordinating care that is both safe and efficient. In high-performance teaming, team members collaborate and share accountability to achieve outstanding results. “Teaming” replaces the previous CLER Focus Area of “Care Transitions.” The properties from Care Transitions were either retired or redistributed as properties of the other 5 Focus Areas.

In all of its activities, the CLER Program remains committed to continuous improvement toward the goal of optimizing the delivery of safe, high-quality patient care. The CLER Pathways to Excellence is part of the ACGME's efforts to help shape a physician workforce capable of meeting the challenges of a rapidly evolving health care environment. The full document is available at https://www.acgme.org/What-We-Do/Initiatives/Clinical-Learning-Environment-Review-CLER.