The Clinical Learning Environment Review (CLER) Program is the latest element in a progression of ACGME efforts to introduce a systems approach to improving patient safety and health care quality into graduate medical education (GME). These efforts began in 1998 with initial efforts that eventually led to the core clinical competencies—especially those relating to communication, systems-based practice, and practice-based learning and improvement.1 In this context, attention to patient safety and health care quality has, over the past 17 years, been incorporated into the ACGME's Institutional and Program Requirements. As will be seen in this report, institutions have included these concepts in the GME curriculum in a variety of ways. In 2009, the findings of the ACGME Duty Hours Task Force (subsequently named the ACGME Task Force on Quality of Care and Professionalism)2 emphasized potential links between fatigue and patient safety, and noted the important role the clinical environment plays in teaching residents how to assess and mitigate risk to achieve the best possible patient outcomes. The Task Force concluded that evaluating the clinical learning environment was necessary to meet the ACGME's mission of “improving health care and population health by assessing and advancing the quality of resident physicians' education through accreditation.” Other studies have also demonstrated the need to focus on the clinical learning environment. Using a 15-year cohort study design of obstetrical care, researchers David Asch and colleagues demonstrated that the clinical site of training is an important predictor of the quality of care provided long after completion of training. Nearly one-third of the differences in patient outcomes in this study could be associated with the site of training, and these differences persisted up to 15 years after graduation from residency.3 An American Hospital Association national survey of hospital leadership found residents and fellows who were starting their careers as independent physicians varied as to their training around systems-based practice issues such as coordinating care with other providers, working effectively with health care teams, and skills in effective communication and information exchange.4 The CLER Program was created to directly explore the clinical learning environment by establishing a periodic site visit program for those US hospitals, medical centers, and clinics that serve as the clinical learning environments for ACGME Sponsoring Institutions. The dimensions and attributes of this program were proposed with the advice of an ACGME-sponsored National Task Force on Patient Safety and Healthcare Quality. This Task Force recommended a site visit program that would be based on a formative evaluation model, and would not directly impact accreditation decisions; would have visits that repeated at periodic intervals in order to document change; and would involve the highest administration leadership of both the GME community and hospital, medical center, or ambulatory care site that was being visited. At its core, the CLER Program has been designed to serve those recommendations. It is a formative evaluation distinct and separate from ACGME accreditation services, with the sole requirement that an ACGME-accredited Sponsoring Institution must periodically complete a visit to remain accredited. The decision to use a formative rather than summative approach to evaluation is built on several underlying premises. First, that there is an overwhelming degree of talent in the GME community and within our nation's clinical learning environments to help drive improvement in patient care. Second, that the GME community and the clinical learning environment leadership and staff all want to deliver the best possible care. Finally, that while standards can be used to ensure safety; standards are not the best mechanism to assist the clinical care and GME systems in each institution to strive for ex
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