Advances in the ACGME Clinical Learning Environment Review (CLER) Program

摘要

Introduction The Clinical Learning Environment Review (CLER) program was launched in late 2012 as a key component of the Accreditation Council for Graduate Medical Education's (ACGME's) Next Accreditation System. The goal of CLER is to provide formative feedback to sponsoring institutions (SIs) on the effectiveness of resident and fellow engagement in 6 focused areas (box), with the intent of continually improving institutional performance in these areas.1,2 The CLER program is intended to serve as a foundation for the Next Accreditation System (figure 1). The only accreditation requirement associated with this new program is that each SI must undergo a CLER visit every 18 to 24?months to maintain accreditation. Upon this foundation of formative feedback and continuous improvement of the clinical learning environment rests the continuous accreditation activities for each SI, residency, and fellowship program. These include annual reviews of program data, a required 10-year self-study process, and a 10-year self-study accreditation site visit. View larger version (56K) FIGURE 1The Building Blocks or Components of the Next Accreditation System Abbreviations: prn, (pro re nata) according to circumstances; RRC, Residency Review Committee; IRC, Institutional Review Committee.;The CLER Program 1?Year After Its First Visit It has been approximately 1?year since the CLER program conducted its first site visit. That visit was the first of several alpha tests conducted in the process of establishing the site visit protocol. Objectives of the alpha test included the following: (1) to develop a set of survey instruments to assess each of the 6 focus areas; (2) to test the feasibility of carrying out a visit on short notice that included group meetings with executive leadership, residents/fellows, faculty members, and program directors; and (3) to assess the capacity of the site visit team to rapidly assimilate and synthesize information about the clinical learning environment and to prepare an oral report of that experience in time for an exit interview at the end of the site visit. Additional objectives included testing the ability of the site visit team to provide a meaningful exit interview and prepare a written report that could be used by the clinical site to improve resident and fellow integration into activities across the 6 focus areas. The CLER site visit protocol has demonstrated its utility and emerged from its alpha testing. The current, extensive beta-testing process will continue through a complete cycle of visits to the primary clinical site of each of the more than 300 SIs with multiple accredited programs. The overall aim of this beta phase is to further test and improve the site visit protocol until a fully mature process has been developed for long-term use. Within this aim, the objectives of the beta test phase are (1) to test the protocol in a broad range of clinical sites and SIs; (2) to demonstrate the ability to scale the visit process to meet a planned schedule of visits to every SI every 18 to 24?months; (3) to gather feedback on the value of the site visit process, including feedback on the CLER oral and written reports; (4) to evaluate the usefulness of a feedback process by which the SI provides the CLER program with a response to the written report; and (5) to test the validity and reliability of the CLER program. More than 80 hospitals and medical centers across more than 40 states (figure 2) have now received a CLER site visit. These visits have been to general acute care hospitals and medical centers and some specialty hospitals, and have included university-based medical centers and independent academic teaching institutions, public and private hospitals, and clinical sites that sponsor a large number of residency and fellowship programs, as well as sites that sponsor a modest number of programs. View larger version (54K) FIGURE 2CLER Program: States Where Alpha and Early Beta Visits Were Completed Abbrev