Challenges and Opportunities in the Six Focus Areas: CLER National Report of Findings 2016

摘要

Introduction In the past decade, national attention has increasingly focused on issues of patient safety and health care quality1,2—and health care organizations and the institutions responsible for graduate medical education (GME) have responded. Executive leaders of our nation's hospitals and medical centers are increasingly using the concepts of high reliability systems3,4 for the purpose of making their health care environments a safer place for patients. These leaders are setting goals for improving the quality of care and implementing systems-based approaches to reach those goals. At the same time, GME has been undergoing a major evolution, adopting competencies and introducing milestones that include a focus on interprofessional as well as patient and family communication and systems-based practice. The ACGME has incorporated elements of patient safety, quality improvement, and professionalism in accreditation requirements; these elements served as the impetus for selecting the six focus areas of the Clinical Learning Environment Review (CLER) Program. Sponsoring Institutions, hospitals, and medical centers are paying increasing attention to educating residents and fellows about patient safety, health care quality, and professionalism as is reflected in the results from the first round of CLER visits. For example, among the residents and fellows interviewed in the group sessions: Approximately three-quarters reported they knew the clinical site's priorities in the area of patient safety. Nearly 95% reported knowing the clinical site's process for reporting an adverse event, near miss/close call, or unsafe conditions. Sixty-three percent reported they had ready access to organized systems for collecting and analyzing data for the purpose of quality improvement. Nearly all reported they have attended institutional training on topics of professionalism and ethics. These findings suggest that clinical learning environments (CLEs) are engaged in efforts to increase awareness of the issues surrounding patient safety and quality through education. The next challenge, for both GME and CLEs, will be to move from the current state of heightened awareness and knowledge to a collaboration that promotes enhanced experiential learning and demonstrated competence in the practices of patient safety and health care quality, and the other CLER focus areas. As in the section reporting on the overarching themes,5 the members of the CLER Evaluation Committee selected the findings shown below after reviewing aggregated data from the site visits presented by the CLER staff.6 The highlighted text presents selected quantitative and qualitative data drawn from the CLER site visits. (For more information on the specific terminology used in describing the results, please refer to the section on detailed findings.)7 The non-highlighted sections that follow present a discussion by the Evaluation Committee of the significance of those findings and the challenges and opportunities within each focus area.;Patient Safety Findings While many CLEs provided didactic training in patient safety, it was uncommon for CLEs to provide residents, fellows, and faculty members with opportunities for experiential learning. In general, residents and fellows lacked clarity and awareness of the range of conditions that define patient safety events and were unaware of how CLEs use the reporting of adverse events and near misses/close calls to improve systems of care, both broadly and at the individual departmental level. Though most residents and fellows were aware of their CLE's process for reporting patient safety events, fewer of them appeared to have used it themselves to report events. When trainees did file a report, or have others file it for them, many received little or no feedback from the CLE. Across CLEs, a limited number of residents, fellows, and faculty members participated in interprofessional, interdisciplinary, systems-based improvement efforts such as