Introduction This section presents detailed findings from the first round of visits of the Clinical Learning Environment Review (CLER) Program, organized into six parts by the CLER focus areas: patient safety, health care quality, care transitions, supervision, fatigue management and duty hours, and professionalism. Between 2012 and 2015, site visits were conducted at major participating clinical sites for 297 ACGME-accredited Sponsoring Institutions (SIs) with three or more core residency programs.1,2 Collectively, these 297 SIs oversee 8,878 ACGME-accredited residency and fellowship programs, with a range of from three to 148 programs per SI (median=17). Because our sample consisted entirely of larger SIs, the institutions surveyed here account for 111,482 residents and fellows—or 90% of all those in ACGME-accredited programs—with a range of from eight to 2,216 trainees per SI (median=241). For each of the 297 targeted institutions, the CLER teams visited one hospital or medical center that served as a clinical learning environment (CLE) for that SI. They spent the majority of their time at inpatient settings, though where possible they also visited affiliated ambulatory care practices in close proximity. The hospitals and medical centers varied in size from 41 to 2,396 acute care beds (median=520). The majority (69.4%) were nongovernment, not-for-profit organizations; 21.5% were government, nonfederal; 5.4% were investor-owned, for-profit; and 3.7% were government, federal. As for location, approximately 30% of them were in the northeastern US, 29.3% in the south, 25.9% in the Midwest, and 14.1% in the west. In the group sessions conducted during these visits, the CLER teams collectively interviewed more than 1,000 members of executive leadership (including CEOs), 8,755 residents and fellows, 7,740 core faculty members, and 5,599 program directors of ACGME-accredited programs in the group sessions. Additionally, the CLER teams interviewed the CLE's leadership in patient safety and health care quality and thousands of residents and fellows, faculty members, nurses, pharmacists, social workers, and other care providers while on walking rounds of the clinical areas. This report is based on a synthesis of all this information, with some data represented quantitatively while other data are described qualitatively. Data sources included answers to closed-ended questions collected through an audience response system, open-ended discussion questions, and interviews from the walking rounds. Mixed methods were used to improve the accuracy of the findings.3 This combination of methodologies and findings should be considered when interpreting the results, making comparisons, or drawing conclusions. For example, results from the group discussions may appear more positive than information gathered on walking rounds. Alternatively, practices reported during group discussions may have been verified on walking rounds. Thus, both supporting and conflicting evidence may be presented to explain or qualify findings.;Patient Safety The CLER site visits explored resident and fellow engagement in patient safety by assessing five major topics: priorities in patient safety, knowledge of patient safety principles and terminology, use of the patient safety reporting system, inclusion in patient safety investigations, and involvement in developing and implementing the CLE's patient safety strategy. Patient Safety Priorities The hospitals and medical centers visited by the CLER Program varied as to their specific priorities for addressing patient safety. However, there were common themes. These included priorities around (1) creating a culture focused on patient safety, (2) improving communications about patient safety, and (3) enhancing use of the patient safety event reporting system. Many of the hospitals and medical centers were also focused on improving their performance on specific patient safety indicators (PSIs), such as infection contr
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