CLER Pathways to Excellence

A 2012 survey by the American Hospital Association found that new residency graduates were deficient in many critical areas, including communication, teamwork and systems-based practice.[1] In response, the ACGME created a new framework for curriculum and evaluation in GME called the Next Accreditation System (NAS).[2] Included as part of the NAS is a detailed description of the Clinical Learning Environment with periodic review and feedback.  The CLER program feedback was created to encourage hospitals and other educational sites to engage resident physicians in the learning process and, by this engagement, improve the quality and safety of the care that is provided.[3]

From 2013 to 2014, the ACGME’s CLER Evaluation Committee, worked to develop the CLER Pathways to Excellence. It is designed with expectations that serve as pathways for each of the focus areas. The CLER Pathways include six focus areas: patient safety, health care quality, care transitions, supervision, well-being, and professionalism.  There are multiple pathways in each of the focus areas, and each pathway includes key properties that can be used for assessment at the institutional level.

NGMC is one of a handful of sponsoring institutions created after the ACGME developed its CLER Pathways to Excellence. These pathways are seen by the ACGME as essential to creating an optimal learning environment.  As you read through the CLER Pathways to Excellence focus areas below (modified from the executive summary of the CLER Pathways to Excellence), imagine how our clinical learning environment will prepare you for the practice of the twenty-first century.

Patient Safety

At NGMC we start every day with Safety.  Each of our 300+ daily huddles begins with a review of the safety tool of the month, a safety story and celebration of good catches.  The culture of safety is a key component of every employee’s job. Our program of “Building Safety CHAMPS” has a goal of ZERO preventable harm.

Communicate Clearly
Handoff Effectively
Act with a Questioning Attitude
Maintain Your Wingman at All Times
Pay Attention to Detail
Speak Up for Safety

For example, the safety tool of the month for February 2018 is “report variances using our reporting system, RL6.”  All residents will be trained on the RL6 system, be encouraged to enter variances regularly and receive feedback from the system on a quarterly basis.  It’s our hope that residents use this system as the basis for their safety project.

Healthcare Quality

It is our goal to deliver high quality, cost-effective care to all of our patients. Our GME program is based on continuous quality improvement, utilizing the PDCA cycle (Plan, Do, Check, Act). Residents are expected to participate in ongoing quality projects, including the “Choosing Wisely” campaign and the yearly Quality Summit.

Residents will receive routine quality reports based on their own patient metrics. These may include preventive measures (e.g., mammogram rates), chronic disease metrics (e.g., mean HgA1c percentage) or hospital measures (e.g., length of stay).

Care Transitions

Transitions of care happen on a daily basis in the acute care setting. Our residents and physicians participate in IDT (Interdisciplinary Team) rounds each day in a variety of settings including the ICU and the inpatient floor.

Supervision

All residents and faculty physicians receive training regarding the ACGME’s supervision requirements. We believe in the process of progressive authority, allowing a resident to obtain more and more autonomy as he/she develops and demonstrates more competence.

Wellbeing

NGMC is at the cutting edge for our wellness program. Our Director of Wellness provides a multi-faceted curriculum based on our core values of respectful compassion, deep interdependence, responsible stewardship and passion for excellence.

Professionalism

We believe that professional identity formation as a physician professional is a key aspect of residency training. We have created cross-specialty learning communities that focus on the development of attitudes and beliefs core to becoming a caring and compassionate physician. Each of the learning communities is led by a physician advisor and meets regularly as part of the Core Educational Curriculum.

References

[1] Combes JR, Arespacochaga E. Lifelong learning physician competency development. American Hospital Association’s Physician Leadership Forum, Chicago, IL. June 2012. http://www.ahaphysicianforum.org/files/pdf/physician-competency-development.pdf. Accessed February 9, 2013.

[2] Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med 2012;366(11):1051–1056

[3] CLER Evaluation Committee. CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, Version 1.1. Chicago, IL: Accreditation Council for Graduation Medical Education; 2017.

[4] Weiss KB, Bagian JP, Wagner R. CLER Pathways to Excellence: Expectations for an optimal clinical learning environment (Executive Summary). J Grad Med Educ 2014;6(3):610–611