Field Report: Getting Prepared for Your Next CLER Visit

In this primer for institutional preparedness, the authors describe ACGME’s Clinical Learning Environment Review and the need to integrate trainees into hospitalwide quality and safety initiatives. 

ABSTRACT: In this primer for institutional preparedness, the authors describe ACGME’s Clinical Learning Environment Review and the need for teaching hospitals to create systems that integrate trainees into hospitalwide quality and safety initiatives. Physician leaders must understand how to improve patient safety and quality by connecting multiple levels of executive leadership and staff to achieve excellent system results.


The mission of the Accreditation Council for Graduate Medical Education is to improve health care and population health by assessing and advancing the quality of resident physicians’ education through accreditation.1 In 2012, it established the Clinical Learning Environment Review program to provide formative feedback to executive leadership and graduate medical education leaders about the clinical learning environment2 in six areas:

  • Patient safety.
  • Health care quality, including health care disparities.
  • Care transitions.
  • Supervision.
  • Fatigue management, mitigation and duty hours.
  • Professionalism.

Preparation for a CLER visit requires both short- and long-term planning. Short-term planning involves preparation of hospital leadership, faculty and residents for the actual visit, while long-term planning ensures that the clinical learning environment has addressed the training requirements set forth by ACGME and the CLER evaluation committee.

While CLER is a formative evaluation, there can be negative consequences to a poor assessment — one will raise concerns about the quality of care and education at the institution and might reflect similar gaps in knowledge and clinical performance of the practicing physicians. Gaps in clinical outcomes and quality metrics can have an adverse financial effect on the institution as payment systems increasingly use quality reporting as criteria for payments to hospitals. Quality of care delivered at hospitals is also becoming more publicly reported. These issues highlight the importance of resident and faculty involvement in hospital quality and safety programs.

What Is the Focus?

CLER is designed to provide institutional leadership with individual feedback aimed at increasing resident, fellow and faculty engagement in patient safety, and improving patient care. Based on early CLER site visits, ACGME believes teaching hospitals, medical centers and ambulatory care sites have great capacity to shape the quality of the emerging physician workforce and drive improvements in patient care.3

There has been growing demand for hospitals to implement quality-improvement tools and techniques in residency training programs.

A survey of designated institutional officials showed many thought the CLER report helped identify previously unknown areas for improvement. A majority of these officials said the CLER report motivated the institution to improve the clinical learning environment and explore new initiatives. In many cases, the CLER report also stimulated increased communication between executive and graduate medical education leadership.4

In January 2014, ACGME released CLER Pathways to Excellence as a guide for the graduate medical education community, teaching hospitals, medical centers and ambulatory care facilities that are training sites for residency and fellowship programs. It emphasized the importance of three distinct professional groups: administrators, faculty physician members and nurses. Many of the pathways stress the importance of interprofessional teams in addressing the six focus areas.2

CLER site visits conducted between 2012 and 2015 included interviews with 8,755 residents and fellows, 5,599 program directors, 7,740 core faculty physicians and more than 1,000 members of hospital executive leadership teams. Among the key findings:

  • Residents lacked clarity and awareness of the range of conditions that define patient safety events and were unaware of how the institutions use the reporting of adverse events and near misses to improve systems of care. And although many of the residents were aware of institutional processes for reporting patient safety events, few actually had reported or received feedback from the institutions if they did.
  • A limited number of residents and faculty members have participated in professional, interdisciplinary, system-based improvement efforts, such as patient safety event reviews and root cause analyses. And although most residents and faculty members were aware of organizational quality-improvement priorities, only occasionally could they accurately identify them.
  • Many residents participated in QI projects during their residency programs, but most had limited knowledge of QI concepts, methods and institutional protocols. In most institutions, residents had limited participation in interprofessional QI teams.5,6

The CLER evaluation committee prioritized the findings from those initial site visits and released four overarching themes to provide clinical learning environments with guidance for systems-based improvements. Those themes emphasized the need to increase:

  • Engagement of residents and fellows in the improvement of patient safety and health care quality.
  • Collaboration between executive leadership and graduate medical education leadership to develop strategic goals for improving patient care, with a specific focus on incorporating residents and fellows in the design and implementation of quality and safety systems.
  • Education and integration of faculty and program directors in patient safety and health care quality improvement.
  • Graduate medical education coordination and implementation of educational activities across health care professions to improve health care quality and patient safety.7

Those themes provide a framework for improving graduate medical education in the clinical learning environment and preparing for CLER visits by addressing the need to increase resident and faculty engagement in patient safety and health care quality improvement initiatives.

Designated Institutional Officials

ACGME requires appointment of a designated institutional official for each sponsoring institution. The official’s responsibility is to oversee and govern ACGME-affiliated programs sponsored by the institution. This person is critical in the clinical learning environment and the CLER site visit. This official helps to coordinate and ensure that programs adhere to all ACGME training requirements, including involving residents in quality-improvement activities throughout the organization. He or she also can help standardize education for all residents within the institution.


Typical schedule and participants for a CLER visit.

  1. Initial and exit meetings with senior leadership.
    • Required: CEO and designated institutional official.
    • Others: Chief medical officer, chief nursing officer, chair (if not designated institutional official) and resident member of the graduate medical education committee, chief operating officer, chief financial officer, dean of affiliated medical school.
  2. Meetings with designated institutional official.
  3. Quality and patient-safety leadership meetings.
    • Attendees: Chief quality officer, chief patient safety officer, chief medical information officer, risk management director (potential).
  4. Group meetings with residents and fellows, faculty members and program directors.
  5. Walking rounds, led by one or more senior residents.
    • Site visitors will interview nurses, residents and other staff about quality and safety issues dealing with residents and fellows. They might ask about incident report submission procedures or how nurses check residents’ capabilities to perform procedures. The site visitor will also observe resident handoffs and timeout procedures.

Source: Accreditation Council for Graduate Medical Education. CLER Site Visit. Accessed Aug. 20, 2017.

Many times, the official will help connect institutional quality initiatives with the graduate medical education programs. This person also is charged with providing and presenting an annual institutional report to the sponsoring institution’s governance board. He or she will lead the preparation for the CLER visit and organize the key players for their sessions. Communication with the C-suite, specifically the CEO, is critical for coordination, support and ultimately the success of the graduate medical education programs.

The official should appraise the most recent annual institutional review and highlight areas in which residents participate in the institution’s quality and safety initiatives. In addition, he or she should review the CLER schedule and purpose of the visit, including the six focus areas of CLER. Ideally, there will be discussion and review with institutional leaders about how the institution is performing in the six focus areas as well as the types of quality improvement projects that involve residents. There also should be discussion about resident participation in patient-safety initiatives and opportunities for systems-based institutional improvement.

Key questions to consider:

  • Who and what form the hospital’s infrastructure designed to address the CLER focus areas?
  • How integrated are graduate medical education leaders and faculty in hospital efforts across the focus areas?
  • How engaged are residents and fellows in patient safety and health care quality-improvement initiatives?
  • How does the hospital determine the success of its efforts to integrate graduate medical education into the focus areas?
  • What are the areas the hospital has identified for improvement?

Requirements and Planning

There has been growing demand for hospitals to implement quality-improvement tools and techniques in residency training programs. The ACGME Common Program Requirements, which govern all residency programs, require that program directors “must ensure that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.”8

Residency programs also are required to establish curriculum to train residents in quality-improvement processes. The key question is how to make the residents and hospital staff more engaged in QI projects and curriculum development. The Institute for Healthcare Improvement offers professional development programs, including conferences, seminars and web-based programs for all levels of staff and executives. The IHI Open School is a free online course that was developed for the next generation of providers, specifically residents and students.9

Educating residents in key concepts of common quality and safety tools — including the cause-and-effect diagram, check sheets, Pareto charts, PDSA (Plan-Do-Study-Act) model, Six Sigma and root cause analysis — is best done by educational sessions followed by use of these skills in hospital QI projects.

An important concept to teach residents is the hospital’s process for reporting errors, near misses, adverse events and unsafe conditions in a protected manner. This process should be outlined as part of the policy and procedure manual for residency programs. In addition, teaching the residents about this topic during orientation and quarterly didactic sessions is essential.

Creating Engagement

Educating residents about institutional quality initiatives is key. Frequent updates are important. Informing residents about critical issues, such as the Joint Commission’s National Patient Safety Goals and major hospital initiatives and programs, is essential. Regular newsletters to residents about hospital initiatives that may be pertinent to their patients effectively communicate essential information. Introducing safety and quality initiatives at annual orientations or compliance training also can effectively start the engagement process. Reminders of key specialty specific topics can be promoted at monthly specialty-specific rotational orientations.

Engaging both junior level and senior residents in various projects is educational and promotes physician leadership training. It also strengthens relationships among interdisciplinary players and enhances opportunities for growth and innovation.

Adding a representative from the QI team to the graduate medical education and resident committees is an excellent way to report the institution’s progress on current QI and safety issues and projects for program directors and residents alike. Residents also can be added to hospital committees — including performance improvement, ambulatory care quality, pharmacy and therapeutics — and to institutional projects regarding clinic flow or hospital throughput.

Being involved with the institutional committees and projects increases resident engagement in institutional quality improvement. Involvement in these decision-making committees will educate residents of the process development and background of how projects are initiated. In addition, their input can be invaluable because they are usually highly involved with so many aspects of care delivery. Participation in root cause analysis is an excellent way for residents to understand and receive feedback on how incident reports, adverse outcomes and near misses are reviewed and action plans are developed. Residents also can provide a “teach-back” of the outcomes and learnings to fellow residents.

Engaging both junior level and senior residents in various projects is educational and promotes physician leadership training. It also strengthens relationships among interdisciplinary players and enhances opportunities for growth and innovation. Executive leadership should recognize graduate medical education’s involvement and contributions to the quality and safety milieu of the institution. Some examples:

  • Our family medicine residency program started “Team-Based Care and Quality Improvement” sessions a few years ago. The clinic created several multidisciplinary teams for team-based care that had quality improvement meetings occurring every two weeks during the residency’s didactic sessions. Each team receives a report of the quality metrics for the patient panel that is assigned to the team. The teams use the PDSA model to make improvements in quality metrics, such as no-show rates and clinic cycle times. Creating healthy competition between the teams increases resident engagement and participation in quality-improvement projects. With these efforts, the clinic has improved its cycle time from 180 minutes down to 80 minutes and decreased no-show rates significantly, from 40 percent to 18 percent.
  • Our orthopedic surgery residency program helped establish a competency center for total joint arthroplasty. Collaboration with preoperative nursing, anesthesia, case managers and rehabilitation personnel allows for prehospital education, appropriate patient expectations, and postoperative management and follow-through. This likely will facilitate better surgical outcomes and higher patient-satisfaction values, as well as cost savings to the institution. Our institution had savings of up to 30 percent on implant costs. There have been additional savings seen in reduced rehabilitation and skilled-nursing facility use because of the increased family education and patient support. Families are better equipped to take the patient home and avoid transfers to rehabilitation or skilled nursing facilities. In addition, this serves as a performance improvement project, and there are various parameters that can be reported on from a scholarly activity standpoint.
  • Offering Lean management training and education to our residents enabled them to participate in programs for clinical service improvements, such as an early discharge initiative and improved clinic throughput. With this initiative, we have improved our discharge order placement before noon from approximately 20 percent to more than 60 percent.


Preparing for a CLER visit involves both short- and long-term strategic planning to ensure a successful outcome. Executive administrative involvement and understanding of CLER will improve the integration of residents and faculty into hospitalwide quality and safety initiatives that have been emphasized by ACGME as a critical aspect of resident training. This integration can promote excellent engagement of practitioners in patient safety and systems-based health care improvements.

Daniel I. Kim, MD, MBA, is the medical director for medical education and the designated institutional official at Riverside University Health System in Moreno Valley, California.

Roger C. Garrison, DO, FACP, is the medical director for inpatient services and vice chair of the Department of Medicine at Riverside University Health System in Moreno Valley, California.

Christine Duong, MD, FACP, is the assistant chief of service for the Department of Internal Medicine and assistant director of graduate medical education at Kaiser Permanente Medical Center in Riverside, California.

Parastou Farhadian, MD, is program director of the Riverside University Health System/University of California at Riverside Family Medicine Residency Program in Moreno Valley, California.

Wade Faerber, DO, FAOAO, is the chair of the orthopedic surgery department and program director of orthopedic surgery residency at Riverside University Health System in Moreno Valley, California.


  1. Accreditation Council for Graduate Medical Education. About Us. Accessed May 1, 2017.
  2. 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.
  3. Wagner R, Weiss KB. Lessons Learned and Future Directions: CLER National Report of Findings 2016. J Grad Med Educ. 2016 May;8(2 Suppl 1):55-56.
  4. Long TR, Doherty JA, Frimannsdottir KR, Rose SH. An Early Assessment of the ACGME CLER Program: A National Survey of Designated Institutional Officials. J Grad Med Educ. 2017 Jun;9(3):330-335.
  5. Wagner R, Koh NJ, Patow C, et al.; CLER Program. Detailed Findings from the CLER National Report of Findings 2016. J Grad Med Educ. 2016 May;8(2 Suppl 1):35-54.
  6. Nasca TJ. Introduction to the CLER National Report of Findings 2016. J Grad Med Educ. 2016 May;8(2 Suppl 1):7-9.
  7. Bagian JP, Weiss, KB. The Overarching Themes from the CLER National Report of Findings 2016. J Grad Med Educ. 2016 May;(Suppl):21-23.
  8. Accreditation Council for Graduate Medical Education. What We Do. acgme. org/What-We-Do/Accreditation/Common-Program-Requirements. Accessed May 1, 2017.
  9. IHI Open School. Institute for Healthcare Improvement. org/education/IHIOpenSchool. Accessed May 2, 2017.

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