1. EMPLOYERS ROLE IN CYBER SECURITY:
CLINICAL LEARNING ENVIRONMENT REVIEW (CLER): SETTING A PATHWAY TO
EXCELLENCE FOR GRADUATE MEDICAL EDUCATION
CREATING A COLLABORATIVE EFFORT WITH GME DEPARTMENTS TO ASSURE SUCCESS
By Barbara Youngberg
As many working in the Academic
Medical Centers environment know, an
important component of their mission is
to prepare future providers to use best
practices to optimize care for their
patients. The month of July marks the
beginning of every new graduate
physician’s career of caring for patients
and contributing to keeping the
environment in which they work safe by
practicing mindfulness and fostering a
culture of respect. In a press release on
January 27, 2014 the American College of Graduate
Medical Education (ACGME) instituted the Clinical
Learning Environment Review (CLER) program as part
of its accreditation program to promote this culture.i
The press release stated:
“This effort creates the framework to reshape the
clinical environments in which tomorrow’s doctors learn
to deliver quality patient care and respond to rapid
developments in health care delivery. Summarized in a
paper published in the January 27, 2014 online edition
of the New England Journal of Medicine and
announced to health care leaders at a policy forum in
Washington, DC, the ACGME’s new guidance called
the Clinical Learning Environment Review (CLER)
Pathways to Excellence represents a roadmap for the
approximately 700 accredited institutions and their
9,000 residency and fellowship programs across the
country to improve resident and fellow physicians’ skills
in addressing issues of patient safety and health care
quality as an essential component of modern medical
practice. The ACGME will also use the Pathways to
Excellence framework as the foundation for issuing
periodic reports on the performance of graduate
medical education (GME) programs in preparing the
physician workforce in patient safety
and quality improvement.” ii
Launched in conjunction with the
transition to the Next Accreditation
System (NAS), the Clinical Learning
Environment Review (CLER) program is
an ongoing initiative to assess the
learning environment at each
accredited teaching institution. As a
critical component of this initiative, the
CLER Pathways to Excellence document
is intended as a guide to improve physician education
in the patient care environments in which residents and
fellows learn, and as such:
 Incorporates findings from more than
100 site visits conducted in 2013 and
input from national focus groups
involving designated institutional officials
(DIOs) and chief medical officers
(CMOs) from GME teaching hospitals,
medical centers and clinics from across
the country
 Defines the expectations for an optimal
clinical learning environment to deliver
high quality and safe patient care while
seeking to educate our nation’s new
physicians
 Lays out the pathways for teaching
hospitals, medical centers and clinics to
improve resident and fellow physician
engagement in six core areas: patient
safety; health care quality; care
transitions; supervision; duty hours;
fatigue management and mitigation;
and professionalism
Financial Services July 2015
Launched in
conjunction with the
transition to the
Next Accreditation
System (NAS), the
CLER program is an
ongoing initiative to
assess the learning
environment at
each accredited
teaching institution.
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2.  Provides tools for institutions to monitor
their progress over time and prioritize
areas for future improvementsiii
Risk managers and patient safety professionals certainly
are cognizant of the unique challenges they face
every July with newly graduated health care
professionals. They often struggle with providing these
recent graduates the information necessary in orienting
them to important risk management and patient safety
topics due to the many competing demands placed
on the incoming resident, as well as the limits on how
much a new physician can absorb without
experiencing information overload and anxiety.
Familiarizing the risk manager and patient safety
professional with the pathways and the expectations of
the CLER program might enable them to design more
focused educational information programs and tools in
conjunction with the office of GME and the attending
physicians supervising new trainees to assure the
highest quality physician workforce.
WHY DID ACGME DEVELOP THE CLER PROGRAM?
The physician workforce is one of the key levers to
improving healthcare. A survey of hospital leaders
conducted by the American Hospital Association
(AHA) found that newly trained physicians were often
deficient in the areas of communication, the use of
systems-based practices, and inter-professional
teamwork. The survey highlighted the need to better
educate U.S. physicians, residents and fellows to foster
improvements in quality.iv Of course many years prior,
the Institute of Medicine (IOM) issued a number of
reports which highlighted the systemic issues that
contributed to the alarming number of preventable
medical errors and challenged providers and provider
organizations to more effectively address the most
common system problems. These systems issues have
been the focus of much of the work done by risk
managers and patient-safety professionals. Many of
these systemic issues are addressed in the pathways
created in the CLER program.
The CLER Pathways to Excellence program was
developed by the ACGME’s CLER Evaluation
Committee, a group that provides oversight and
guidance on all aspects of CLER program
development. The CLER Evaluation Committee
represents a broad range of perspectives. Members
were selected based in their national and international
expertise in areas of patient safety, healthcare quality,
fatigue mitigation, hospital administration, graduate
medical education and patient advocacy. The
development of the CLER Pathways to Excellence was
formed by the expertise of the committee members,
selected published literature, input from the CLER field
staff (based on over a hundred site visits) and input
from focus groups of chief medical officers and others
from GME teaching institutions across the country. v
The program will be based on principles of continuous
quality improvement and will evolve over time to
reflect what is learned from the site visits, as well as
input from GME leadership, the executive leadership of
ACGME, accredited teaching hospitals, other clinical
sites and the community.
HOW DOES THE CLER PROGRAM WORK?
Site visits will be conducted by the CLER
Evaluation Committee during which residency
sites will be evaluated against the specific
pathways. The purpose of the site visit is to
evaluate, encourage and promote improvements
to the clinical learning environment. The CLER
program provides the sites visited with three types
of formative feedback: an oral report at the end
of the site visit, a written narrative report
summarizing the site visitor’s observations and, in
the future, a report that will provide national
aggregated and de-identified data displayed
along a continuum of progress towards achieving
optimal resident and fellow engagement in the six
focus areas. vi
During the site visit, members of the CLER site visit
team meet with the senior leadership of the
organization and with those individuals responsible
for patient safety, healthcare quality and
informatics, and GME. In addition, they meet with
residents and fellows along with faculty members
and program directors. The CLER team also visits
units and clinics where care is provided in order to
assess the culture of learning in place in the
organization.vii At the conclusion of the site visit
the CLER team will meet with the organization’s
team to de-brief and share preliminary findings
and impressions.
While the CLER site visit program is part of the NAS,
it is separate and distinct from nearly all
accreditation activities. There are two essential
elements that connect CLER with the rest of the
accreditation process. The first is that each
sponsoring institution is required to periodically
undergo a CLER visit (currently targeted to occur
every 18-24 months). The second is that the Chief
Executive Officer and the leader of GME
(specifically the Designated Institution Official
(DIO)) for the clinical site must attend both the
opening and closing sessions of the CLER visit.viii

3. THE RISK MANAGER’S ROLE IN CLER
ACCREDITATION
As is obvious, the risk manager, patient safety
officer and quality improvement staff can assist
their organization in achieving success in the CLER
Pathway to Excellence program. To avoid
redundancy of effort and to assure the best
resources in the organization are brought to bear,
the 40 page document developed by ACGME
should be reviewed by all staff who will play a role
in CLER accreditation
(https://www.acgme.org/acgmeweb/Portals/0/P
DFs/CLER/CLER_Brochure.pdf). Although the
various pathways which form the basis of the
assessment are found in the appendix of this
article, the ACGME document describes in
greater detail the specific properties that would
lead the assessment team to conclude the
organization was on the pathway to excellence.
As would be suspected, many of these properties
are organizational attributes which risk
management and patient safety professionals
already know are present in a robust culture of
safety.
 Meet with GME director or DIO to discuss
the role which the risk management,
patient safety and QI departments can
play in helping GME program meet CLER
goals. Identify areas of existing expertise.
 Encourage reporting of actual and near
miss events by residents and fellows. You
may do this by creating easy “how to”
pocket card detailing how to report an
event and what will happen once the
event is reported. You may wish to create
some campaigns which focus on the
reporting and analysis of specific event
types that might be most relevant to
residents and fellows (these might include
events occurring due to failed hand-off
protocols, events that are related to fatigue
or burnout or events where a hierarchical
structure may have contributed to failed
communication).
 Verify that the event reporting system has a
data field for easily identifying events
where residents and fellows are involved
and when systemic factors include those
commonly cited by ACGME
(communication failure, handoff failure,
fatigue, supervision etc.).
 Prepare an annual survey (to be offered in
June) to measure impact of efforts to
support residents and fellows in support of
patient safety.
 Invite residents and fellows to sit on risk
management, patient safety and QI
committees to review the events reported
and to identify solutions. Include them in
the root cause analysis or FMEA’s where
residents and fellows are involved. Provide
them with clinical data used to evaluate
trends and identify opportunities for
improvement. Residents and fellows will
need to be convinced early on that the
time they spend reporting events will make
a difference in the care their patients
receive. Early on, students struggle to
balance all of the competing priorities and
pressures of being a new physician, and it
will be important to demonstrate the value
of reporting by providing timely feedback.
 If the organization has an intranet, the CLER
program should be described and the
individual roles that residents and fellows
play to assure the program’s success should
also be described. In addition, brief
articles should be posted that relate to
each of the CLER pathways especially
those that relate to educational principles
and practices of patient safety such as
communication, culture, fatigue, hand-offs,
supervision, managing disparities, proactive
risk management practices that support
patient safety and use of data to drive
improvement.
 Involve residents and fellows in
disclosure training that is offered to all
medical staff. Use simulation techniques if
possible.
 Identify tools and templates that have
been designed by the organization to
facilitate and standardize the hand-off
process. Make certain residents and fellows
are aware of these tools.
 Identify residents and fellows who can be
designated champions and mentors. They
can assist in promoting these practices
among their peers.

4. ABOUT THE AUTHOR
Barbara J. Youngberg has joined Beecher Carlson as a
Consultant to the national healthcare practice. She has
more than 25 years of experience in the healthcare
industry focused on legal and regulatory issues, risk
management and patient safety concerns and internal
operations in academic medical centers and complex
teaching hospitals. Barbara currently works as a Visiting
Professor and Director Faculty of the On Line Programs
at the Beazley Institute for Health Law and Policy at the
Loyola University College of Law in Chicago. Contact
Barbara Youngberg at
barbara.youngberg@gmail.com.
Disclaimer
This article is intended for informational purposes only. It is not a
guarantee of coverage and should not be used as a substitute for an
individualized assessment of one’s need for insurance or alternative
risk services. Nor should it be relied upon as legal advice, which
should only be rendered by a competent attorney familiar with the
facts and circumstances of a particular matter.
Copyright Beecher Carlson Insurance Services, LLC. All Rights
Reserved.
i
http://www.acgme.org/acgmeweb/portals/0/pdf
s/cler/acgmeclernewsrelease.pdf (accessed June
14, 2015)
ii
http://www.acgme.org/acgmeweb/portals/0/pdf
s/cler/acgmeclernewsrelease.pdf (accessed June
14, 2015)
iii
http://www.acgme.org/acgmeweb/portals/0/pdf
s/cler/acgmeclernewsrelease.pdf (accessed June
14, 2015)
iv
Combes.JR,Arespacochaga.E , American Hospital
Association Physician Leadership Forum Lifelong
Learning:Physician Competency Development
,Chicago,IL:American Hospital Association;June.2012
www.ahaphysicianforum.org/files/pdf/physician-
competency-development .pdf (accessed 6/14/2015)
(Accessed.February.9,.2013)
v
https://www.acgme.org/acgmeweb/Portals/0/PD
Fs/CLER/CLER_Brochure.pdf (accessed 6/11/2015)
vi
https://www.acgme.org/acgmeweb/Portals/0/PD
Fs/CLER/CLER_Brochure.pdf (accessed 6/11/2015)
vii
https://www.acgme.org/acgmeweb/Portals/0/PD
Fs/CLER/CLER_Brochure.pdf (accessed June 14,
2015)
viii
https://www.acgme.org/acgmeweb/Portals/0/PD
Fs/CLER/CLER_Brochure.pdf

5. APPENDIX
CLER PATHWAYS TO EXCELLENCE viii
PATIENT SAFETY PATHWAYS
#1 – Reporting of adverse events, close calls (near misses)
#2 - Education on patient safety
#3 - Culture of safety
#4 – Resident / fellow experience in patient safety
investigations and follow-up
#5 – Clinical site monitoring of resident / fellow
engagement in patient safety
#6 – Clinical site monitoring of faculty member engagement
in patient safety
#7 – Resident / fellow education and experience in
disclosure of events
HEALTH CARE QUALITY PATHWAYS
#1 – Education on quality improvement
#2 – Resident / fellow engagement in quality improvement
activities
#3 – Residents/ fellows receive data on quality metrics
#4 – Resident/ fellow engagement in planning for quality
improvement
#5 – Resident / fellow and faculty member education on
reducing health care disparities
#6 – Resident / fellow engagement in clinical site initiatives
to address health care disparities
CARE TRANSITIONS PATHWAYS
#1 – Education on care transitions
#2 – Resident / fellow engagement in change of duty hand-
offs
#3 – Resident / fellow and faculty member engagement in
patient transfers between services and locations
#4 – Faculty member engagement in assessing resident –
related patient transitions of care
#5 – Resident / fellow and faculty member engagement in
communication between primary and consulting teams.
#6 – Clinical site monitoring of care transitions
SUPERVISION PATHWAYS
#1 – Education on supervision
#2 - Resident / fellow perception of the adequacy of
supervision
#3 – Faculty member perception of the adequacy of
resident /fellow supervision
#4 - Roles of clinical staff members other than physicians in
resident / fellow supervision
#5 – Patients and families, and GME supervision
#6 – Clinical site monitoring of resident / fellow supervision
and workload
DUTY HOURS, FATIGUE MANAGEMENT AND MITIGATION
PATHWAY
#1 – Culture of honesty in reporting of duty hours
#2 – Resident / fellow and faculty member education on
fatigue and burnout
#3 – Resident / fellow engagement in fatigue management
and mitigation
#4 – Faculty member engagement in fatigue management
and mitigation
#5 – Clinical site monitoring of fatigue and burnout
PROFESSIONALISM (SELECTED TOPICS) PATHWAYS
#1 - Resident / fellow and faculty member education on
professionalism

6. #2 – Resident / fellow attitudes, beliefs, and skills related to
professionalism
#3 – Faculty engagement in training on professionalism
#4 – Clinical site monitoring of professionalism