Clinical Learning Environment Review (CLER) Visits: A Meeting Point for GME and CME

Published Date

Timothy P. Brigham, MDiv, PhD,  Chief of Staff and Senior Vice-President, Accreditation Council for Graduate Medical Education (ACGME) describes the role of CLER visits and CME in creating a culture of quality improvement in residency training programs, in a discussion with Kate Regnier, MA, MBA, ACCME Executive Vice President.


>>REGNIER: OK. So, let’s switch from the milestones to the CLER Visits.


>>REGNIER:  And talk - I’m particularly interested in, sort of, the impetus of the CLER Visits how they’re being structured and what I see as a real opportunity to bring together,

>>BRIGHAM: Right.

>>REGNIER: to fulfill a whole bunch of different purposes



>>BRIGHAM: Right

>>REGNIER: all to benefit the patients.

>>BRIGHAM: The first line of our mission is to improve the health of the public through accreditation and education of our residents. Our board, our C chairs really almost tattoo that on their heart. And they changed the name of the Duty Hours Taskforce to the Taskforce on Safety and Quality. And from that committee that worked over a year, they came up with the CLER Visits. One of the things that the IOM criticized the ACCME on was not being, not being vigilant enough on our institutions and our program. We took that to heart developed these CLER Visits, where, as I said before, every eighteen months every institution sponsoring institution in the country will be visited. We, it’s very exciting in a lot of ways, Kevin Weiss, who’s our Senior Vice-President, who you should interview, by the way at some point, has just gone through the alpha and beta phase of developing these visits and the news has been really encouraging. One of the most exciting portions of that is that we’re not just engaging the typical cast of characters, the DIO, the program directors and residents. One of the most important pieces that we’re doing here is that we’re engaging the C-suite, the CEO, the Quality and Safety Officer within the hospital and that has proven to be a really, really great thing. These CLER Visits, by the way, are in a special sort of gray zone; they are not accreditation visits. They are visits that are peer visits from some professional site visitors and we’re actually adopting a model that you use. We’re going to have trained peers from other sponsoring institutions go to a sponsoring institution A to visit them.

>>REGNIER: I had the opportunity to hear Kevin,


>>REGNIER: and Robin,


>>REGNIER: Robin Wagner


>>REGNIER: speak at the AIAMC


>>REGNIER: National Initiative III meeting not too long ago a couple of weeks ago here in Chicago and Kevin was describing exactly what you are talking about in terms of these being data points, descriptive of the system but not necessarily of the data points that are sort of going to be count against or be factored in to the accreditation process.

>>BRIGHAM: Right.

>>REGNIER: And this idea, it’s one that we’ve really struggled with and heard from our accredited providers quite a lot about, which is this challenge of engaging the C-Suite.


>>REGNIER: This challenge of getting the time and attention of the CEO or the CFO or the Chief Medical Officer in terms of really understanding the value of what’s there in their own institution. And so talk about that, they describe sort of a typical schedule and the big value that appears to be coming out of these visits.

>>BRIGHAM: Well, it’s, the typical schedule has a couple of points where they meet formally with people starting with the CEO and ending with the CEO.

>>REGNIER:  Right.

>>BRIGHAM:  Where they talk with the CEO, get his or her perspective on this, and the Chief Medical Officer go out and just talk to people on the floors of the hospital, engage residents in a formal way, engage them in an informal way etcetera. There’s a, they have what Robin and Kevin have done is built in a number of feedback loops to the institution. Again, with the goal of this being collegial quality improvement enterprise.

>>REGNIER:  So, the idea is looking for a back to the acronym of CLER, right. Is it looking for the residents’ involvement in


>>REGNIER: quality improvement?


>>REGNIER: Sort of the quality improvement environment not just individual one-off projects?

>>BRIGHAM: Right, yes. So, they’ll ask residents things like, Can you describe a near miss? And if the resident looks at them like they have a deer in the headlights that’s the first area where they sort of explain what that is and what they do with it. If they, if the residents are facile with that terminology, the next question will be OK what do you do when you have a near miss, can you give an example? So, we really, I mean through this sort of gentle way of questioning and giving feedback, they have managed in the alpha and beta phases, at any rate, to get to the real root of some of the issues. Feed that back as information, it’s almost what you described with the physicians, giving them data that feeds back to the CEO about what’s happening with his or her

>>REGNIER: So they can make their organization better.

>>BRIGHAM:  Right. Now, I’ve said that this is not an accreditation visit, but if we find some places that are unusually toxic or there’s egregious things going on this will, of course, go to the institutional review committee for some sort of accreditation action.

>>REGNIER: But these are

>>BRIGHAM: But we’re trying very

>>REGNIER: they’re separate visits, right?

>>BRIGHAM: they’re separate visits

>>REGNIER: an institutional visit, a CLER Visit.

>>BRIGHAM: There is a separate visit, there is a separate committee that’s looking and assessing the institutions in the CLER Visits that is not an accreditation committee that’s composed of patient safety experts from around the country. And again the goal is to give them the information, help them improve, and then go back in eighteen months and see if they’ve done something with it.

>>REGNIER: So, you and I’ve had the opportunity to talk about sort of the, the involvement of the faculty

>>BRIGHAM: Right.

>>REGNIER: and the goal that this really is sort of a marriage between CME, GME, QI all to promote the, the, improvement in patient care. AIAMC we’ve also talked about

>>BRIGHAM: right

>>REGNIER: the fact that their national initiatives for QI, this last round this NI III really is focused on those three being brought together.

>>BRIGHAM:  Yes.

>>REGNIER:  And I was struck in listening to Kevin’s presentation at this NI III conference, that those organizations are already doing or sort of living or reflecting what the CLER Visits are looking for. You think that’s fair?

>>BRIGHAM: That’s what we want; I mean that’s what we want to have happen. Now, one of the things that sparked this was a question that Tom Nasca got at one of our annual conferences saying, How can we be expected to teach the residents quality and safety when we don’t even know anything about it? And Tom’s response was, that was an OK response to the question 10 years ago, but that’s not an OK question now. So what we’ll be depending on there’s a huge part for CME in this.

>>REGNIER: Right.

>>BRIGHAM: But, depending on getting the faculty up to speed.

>>REGNIER: Exactly. Not OK now the CME and QI aren’t interacting.

>>BRIGHAM: Correct

>>REGNIER: If that’s the case, right?

>>BRIGHAM: The faculty have to be able to ask the questions I said Kevin’s asking now, of the residents. The faculty have to be the ones that are helping and guiding the residents to actually integrate and engage with the institution. What’s one of the things that’s most interesting to me is that if you want to know what’s going on in your hospital, ask a resident. They know all the places where things are going really well,

>>REGNIER: The good stuff and not so good stuff.    

>>BRIGHAM: what’s not going well and most of them can offer, in a couple of sentences, ways to improve all the things that are not going well that would be pretty cost effective ways of doing things. And they see where the, where all the, I don’t want to say it, but where all the secrets are being held, but they’re not secret because the institution’s not necessarily aware of what the residents are aware of. So, to go back to your point though, there’s a huge need for the faculty to understand the safety and quality language, the safety and quality concepts and to engage in the safety and quality movements of their own institutions. The residents cathect onto a faculty member you know like young goslings do on a goose if they don’t see the faculty doing what we’re expecting the residents to do the half-life of what it is they’re quote unquote learning is minuscule it goes away in a second. If the faculty demonstrate and role model these, the knowledge, skills, behaviors that are necessary to take patient safety to the next level, which we all like to do in the United States, that’s when it becomes a really powerful thing. And that’s where, CME I think, will make real progress.

>>REGNIER: it’s a real synergy

>>BRIGHAM: I think, it’s not just a synergy, that’s where you have a responsibility; that your providers have a responsibility to get in there with the quality improvement people, with the patient safety people and help educate them in the fullest sense of the word, not just in terms of their knowledge, but in terms of their behavior also. To develop maybe milestones in outcomes based kinds of things

>>REGNIER: to use your terminology

>>BRIGHAM: Well, to use yours. I mean every outcome doesn’t have to be a patient outcome,

>>REGNIER: Perfect.

>>BRIGHAM: the outcome can be in the behavior of the physician.


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