A CLER Window: Aligning GME, CME, and Institutional Goals

Published Date

Steve Singer, PhD, Vice President, Education and Outreach, interviews Josephine Fowler, MD, Former Vice President, Academic Affairs/DIO, JPS Health Network about the Clinical Learning Environment Review (CLER) process and how it utilizes continuing medical education (CME) to measure graduate medical education (GME).


>>SINGER: Hi, my name is Steve Singer. I'm the Vice President for Education and Outreach at the Accreditation Council for Continuing Medical Education. My guest today is Josephine Fowler. I'm going to talk with Josephine today about continuing medical education and graduate medical education, and some great opportunities to work together. Hi, Josephine.


>>SINGER: Thanks for joining us today.

>>FOWLER: Thanks for inviting me.

>>SINGER: When I look at your title, I see Chief Academic Officer and Designated Institutional Official. Can you explain a little bit about these roles that you have?

>>FOWLER: Yes. So in my current role, I have oversight for medical education but also for continuing medical education. So in my role as Chief Academic Officer, our office is actually the administrative part for medical students, residents, PA students, and then on the CME side, we are responsible for the faculty development and for physician education.

>>SINGER: I probably should have asked this first, but JPS is a community hospital?

>>FOWLER: Yes, JPS is a public hospital.

>>SINGER: Public hospital.

>>FOWLER: And it is an independent academic medical center.

>>SINGER: Okay, and as you said, you teach students, residents, the whole works.

>>FOWLER: The whole scope.

>>SINGER: Okay. So I think that what we'll divide our conversation sort of in two parts.

>>FOWLER: Okay.

>>SINGER: The first part is, I want to talk about the CLER process, Clinical Learning Environment Review.

>>FOWLER: Yes.

>>SINGER: Because this is a relatively new entity, and your organization has participated in the CLER process?

>>FOWLER: Yes, we've gone through two cycles.

>>SINGER: Two cycles.

>>FOWLER: We were part of the first beta visits, and part of that came along because we were active in the Alliance of Independent Academic Medical Centers. And we have been doing similar initiatives now for about six years.

>>SINGER: All right. So can you describe to us a little bit, the CLER process is a program of the Accreditation Council for Graduate Medical Education, who is the national accreditor for residency programs.

>>FOWLER: Yes.

>>SINGER: And the CLER process was a process created to get some information, some data, about the clinical learning environment. So from your standpoint, can you explain how this came to be, how it came to your desk?

>>FOWLER: So in my role as DIO, of course I'm responsible for the accreditation of the residency programs. And in this role, I've taken part with the Alliance in looking at ways to bring GME to the forefront of looking at quality and patient safety. And so when the CLER process came, of course, in the one hand just strictly about the accreditation, and the other area having that skill set that had been developed over last several years, and looking at quality and patient safety, we decided that it's something that we should actually lead from our office. So in our office, we're not the only people that are involved in CLER, but we're the... For lack of better words, the think-tank about how this is going to go.

>>FOWLER: And so we have members on our team that are members throughout the institution, and that could be someone from the quality department. Currently we're working on projects related to health disparities, so we have our Executive Director of Diversity and Inclusion on our team. We have residents on our team, we have faculty on our team. And we look at things that are in the learning environment that are... Maybe we need to have change, transformation, or things that we need to better to reach certain marks as measured by evidence-based medicine. And we look at those and we set up many performance improvement or quality initiatives to make that better for the institution.

>>FOWLER: Part of that change and transformation includes education because in order for our faculty or our residents to be involved, they need to know how to do the process. So we've utilized CME to actually teach people things like Lean Six Sigma, PDSA cycles, change management. And we use CME for that vehicle. In addition to that, for the faculty, we literally, at the beginning, began by teaching each of the elements of the CLER process, and we had a retreat. And in that retreat we had sessions on professionalism, not just an overall lecture on professionalism, but how do you measure it with residents? And then we also had topics on things like quality, where we review the metrics of the hospital because one of the things that was noted in our first CLER visit is that the residents have been involved in this initiative, so they knew what the hospital was doing. But the faculty in each department, they have their own initiatives. And they couldn't tie it back to the overall... What the hospital was doing.

>>FOWLER: So part of the workshop and the faculty development utilizing the CME was to say, "Okay, these are the main objectives of the hospital. And so we realize that you're doing many tasks in your department, but we want to be aligned with what the C-Suite is doing." And that's something we learned from participating in the Alliance initiatives. The first part of that is engaging the C-Suite and engaging GME to be aligned with the C-Suite, and so that was really important for us. So part of the training wasn't all about what is the medical outcome, it was more about how do we make this happen? How do we become an interdisciplinary learning team, and how do we get people to understand the steps and the process in making this happen for our institution and improving our outcomes? So we talked about what is PDSA. We had someone to come in and talk about what is root cause analysis. What is reporting and why do you report not only near-misses or things that aren't going well, but we need to report good catches because maybe something we can learn in department eight...

>>SINGER: What went well, right?

>>FOWLER: Yeah, it could be generalized to the entire institution. So we have been able to intermingle the education along with the actual activities that are going on in the hospital.

>>SINGER: So Josephine, tell me about... What was the CLER process and what happened?

>>FOWLER: So the CLER process is not accreditation; it's actually to look at the learning environment where the residents are training, and to make sure that everyone is aware of what's needed for residency training, and to make sure it's a safe environment. So it looks at supervision, it looks at duty hours, and fatigue management, professionalism, looks at transition of care, and then quality and patient safety. And...

>>SINGER: Okay. And... Oh, go ahead.

>>FOWLER: And so those are the major areas that they're looking at when they come out. They usually spend two days with this, and there's a schedule, about every hour there's something different. Throughout the process, the visitors actually conduct focus group sessions with residents, with faculty, with the C-Suite, with key people in the learning environment such as the Chief Quality Officer. And they met with the Chief Nursing Officer and the Chief Operating Officer, and then they talk to the program directors. And they meet with these different groups and they ask them what do they think about the learning environment, and what are some of the main objectives of the organization, and how does GME fit into those objectives? But...

>>SINGER: So it's an observational study, in a way.

>>FOWLER: Yes.

>>SINGER: And what came out of the process? Is there a debrief at the end of the process?

>>FOWLER: So there is a debrief because in addition to what I mentioned earlier, they walk around the hospital.

>>SINGER: Okay, so get from different stakeholders a 360 degree assessment.

>>FOWLER: Assessment. And from that, they give you a report on how your team has responded in all of those areas. They're looking for two things: One, that there's actually activity in the clinical learning environment that's providing a safe environment for patients and quality of care. Secondly, they're looking at what is the actual consensus among the group about what we're doing in the learning environment? Are we aligned with the C-Suite and their goals and objectives? And are we all speaking the same language? Are we actually setting the same quality points, are we looking for the same outcomes, or is it just a system where everybody's doing everything.


>>SINGER: Now, did you get an A plus?

>>FOWLER: We did fairly good.

>>SINGER: Is everything aligned?

>>FOWLER: Everything's aligned. There were some areas... So in the first visit, the residents were well aware of what the C-Suite was doing because we've had lots of education about it. And the program directors were aware and the faculty. But when they talked to the chairs and some of the other physicians, they may have stated some other objectives. Now, subsequent to that, before our next meeting, we had retreats, and we learned about what our hospital was doing. In addition to that, we made it actually an institutional objective to make sure that the information from the C-Suite is being channeled down throughout the organization.

>>SINGER: It's interesting, and you said that the... And it's not surprising that the students, as the freshest young learners in the system, are getting the direct benefit of the interaction among these different departments and from the strategic leadership clinical, etcetera. But you mentioned that some of the higher-level... That it might seep into the faculty as well. But some of the higher-level leaders did not have the same benefit of that connection. So what did you do in order to try to ameliorate this disconnect?

>>FOWLER: So shortly after realizing that this needed to go throughout the faculty and the physician group, even those that are not faculty, we had a retreat, and we called it the Quality and Patient Safety Initiative, actually. And on the retreat, we had basic things about what is CLER then we talked about each element. And we had a speaker talk about those, not just giving a lecture, but talking about how it actually feeds into the clinical learning environment. For example, there was a session on PDSA cycles, there was a session on root-cause analysis. All the people in attendance got a white belt in Six Sigma, and some people have subsequently gone on to get their yellow belts and their green belts.

>>SINGER: Okay. So it became... There were a number of benefits, but it became a professional development opportunity.

>>FOWLER: Yes.

>>SINGER: But it also became a way... You're bringing these things from CLER, it's almost the CLER process as an observational event...

>>FOWLER: Yes.

>>SINGER: Was a way to bring some data about practice-based gaps, institutional gaps, to this community.

>>FOWLER: Yes.

>>SINGER: Okay. Now, you haven't said it yet, but were these educational, or these training interventions, were they part of your CME program?

>>FOWLER: Yes, they were.

>>SINGER: Okay. And wow! Because you sit in a very unique perspective that I wonder how many of your colleagues who are watching this share that perspective, or if they are more remotely connected between the GME or graduate medical education personnel and the continuing medical education or continuing education personnel. So you... Or, I shouldn't say you, your organization has the good fortune that you're the person. So you're both the DIO and the CME person. Can you share with us what the benefit was of being the same person and being able to provide CME?

>>FOWLER: Yes, so the largest benefit is that you don't have to really sell your idea to someone else because you're making...

>>SINGER: Yeah, right. It's like look in the mirror, and...

>>FOWLER: You're like, "Self, we're going to do this." But being realistic about it, the largest benefit is the fact that we have... On the GME side we have the instructions for the CLER visit, and we have the information about our organization. On the clinical side, we have the physicians and the clinical staff that can tell us where the gaps are. And if we match those gaps, we can add that training to the people where it matter most: The residents who are on the front line, and the trainees, and the faculty who are teaching them. Because we want them to be able to mentor the residents in how to solve the issues that are in the clinical environment. One of the areas is transitions of care. The residents are first to notice that maybe there's something we need to improve to make a systematic approach in how we do hand-offs or how we do discharge planning. And then going back to CME, we talk about what are best practices. And then once we find out what those best practices are, we disseminate throughout the organization.

>>SINGER: Right. So it's interesting, there's so many ways to look at this. It's not hard for people when they look at the CLER program to see its own benefit as part of the... Doing the best that you can for the learners in that environment, and not just residents, but other trainees whether it be in nursing or other disciplines?

>>FOWLER: Correct.

>>SINGER: But what you've brought to this conversation, and also brought to your institution, is that it's not just to make the best of the clinical learning environment, but to understand that the clinical learning environment is a window and a very strategic vantage point to really understand the vulnerabilities as well as the opportunities of that as the leading edge in clinical care interactions and other interactions that have a strategic bearing on the institution. So that's fascinating. So you've come through two of these processes?

>>FOWLER: Yes.

>>SINGER: So this is old hat now for the organization, sort of part of your improvement program. Is this observational data together with the training that you're doing?

>>FOWLER: Yes.

>>SINGER: What's next?

>>FOWLER: So what we are doing, for example, as an executive I have an executive metric, so I have multiple metrics every year that I have to monitor. So one that I chose this year that was related to CLER and related to something the hospital is doing is to look at preventable injuries because we see preventable injuries among our trainees. So we decided that we would track, pre-education, how many injuries they have the previous year, and then we would do a needs assessment to see what are the top perceived reasons for the preventable injury among the faculty and among the people who receive the injury. And we actually did a survey, and then we got those top 10, and then our plan is, as we plan out our year, academic year, and we have a session called Business of Medicine, we have a series called Business of Medicine, we would address those and look at the evidence about how to prevent those: Needle sticks, how do you prevent... We have people falling. How do you prevent falls in the workplace? And what are some other institutions doing to adjudicate repetitive injuries among our employees?

>>FOWLER: So that's one way that we're addressing a need of the institution, we're preventing injuries among our learners and our employees, and we're using CME to address what is the best practice, what are people doing to decrease these rates because those things happen in hospitals all across the country.

>>SINGER: Yeah. And it's important for the folks that are watching to realize that all of these strategies that you described also meet our expectations for where we're going with accreditation with commendation, so that in a new section of this menu of commendation criteria, we have criteria about enhancing outcomes. And among those outcomes are not only individualized outcomes, changing performance for individual faculty, professionals, what have you, but also addressing system-based issues or process issues and patient outcomes as a whole. So all of this is consistent with that, so I think the way also that you connected it to executive objectives or expectations... Maybe incentive is not the right word, but it's this idea that you in this role, and with the support of your leadership, have found a way that CME and GME can both be valued and resources to do what's important to the medical center overall, which I think is fantastic.

>>FOWLER: Yes.

>>SINGER: Thank you very much for joining us.

>>FOWLER: Thank you very much.