Pursuing Excellence in Clinical Learning Environments

摘要

Introduction Over the past decade, health care organizations have increasingly focused on developing and implementing systems-based approaches to improving patient care. The specific areas for these innovations have varied, but the approach has typically involved interdisciplinary teams of professionals working together to standardize on evidence-based practices, reduce errors, and achieve continuous quality improvement. Concurrent with these changes, the Accreditation Council for Graduate Medical Education (ACGME) and other national organizations have been reexamining the nation's graduate medical education (GME) system to address evolving needs in the area of the quality and safety of patient care.1–3 Studies have demonstrated that residents' clinical learning environments can influence their practice patterns over their clinical careers.4–6 One study showed, for example, that residents who train in areas where aggressive medical management is the norm tend to choose more aggressive measures later in life, even in cases where conservative care may be as or more appropriate.5 Another study found that physicians who trained in regions with relatively high per-capita health costs continue to practice in a higher-cost manner for up to 2 decades later, even if they have moved to a lower-cost region during the interim.5,6 In 2012, the ACGME launched the Clinical Learning Environment Review (CLER) to provide feedback to the nation's teaching hospitals and medical centers on how successful they are at engaging residents to improve quality and safety in the systems of patient care in which they learn and participate.7 Over the 3 intervening years, CLER representatives have site visited hospitals, medical centers, and ambulatory sites of 297 sponsoring institutions. At each site, they have conducted group meetings and in-person visits to individual clinical units. Their observations have focused on the 6 areas defined by the CLER Evaluation Committee in its Pathways to Excellence document,8 which encompass patient safety, health care quality (including health disparities), care transitions, supervision, fatigue management and mitigation, and professionalism. At the conclusion of each visit, the site visitors have shared their feedback at a meeting with the administrative, clinical, and educational leaders of the institution, highlighting areas of strength and opportunities for improvement. The CLER program will publish a detailed report of findings from this first cycle of site visits in a supplement to the Journal of Graduate Medical Education later this spring. Four overarching key findings will be presented as part of the larger body of findings in that report. They include: Clinical learning environments vary in their approaches to and capacity for addressing patient safety and health care quality, as well as the degree to which they engage resident and fellow physicians in addressing these areas. Clinical learning environments vary in their approach to implementing GME. In many clinical learning environments, the approach to GME is largely developed and implemented independent of the organization's other areas of strategic planning and focus. Clinical learning environments vary in the degree to which they coordinate and implement educational resources across the health care professions. Clinical learning environments vary in the extent to which they invest in continually educating, training, and integrating faculty members and program directors in the areas of health care quality, patient safety, and other systems-based initiatives. The CLER program found a high degree of variability both between and within institutions with regard to practices in all 6 focus areas. Currently, little is known about what underlies this variability, either for patient care or for the training of residents and fellows. We believe it is essential that this variability be studied so that innovations and successful practices can emerge to characterize