What the “CLER National Report of Findings 2021” Showed Us About the CLER Focus Areas

 Author: Treven W. Cade

With the “CLER National Report of Findings 2021” (hereinafter CLER Report) being released earlier in October, Germane wanted to highlight the common challenges that were identified in Clinical Learning Environments (CLEs) regarding the six Clinical Learning Environment Review (CLER) Focus Areas (patient safety, well-being—which is the newest Focus Area—, health care quality, care transitions, supervision, and professionalism). The CLER Report illustrates detailed findings and themes for each Focus Area, and the CLER Evaluation Committee present additional key findings for patient safety and well-being specifically. The discussion below will illustrate these pertinent themes and findings for each Focus Area to give programs a look into common issues that CLEs face; therefore, programs can become cognizant of these commonalities within their own operations.

Developing what was mentioned previously, the CLER Report identifies three overarching themes, two patient safety findings, five well-being findings, and detailed findings for all six CLER Focus Areas. Patient safety and well-being were selected by the CLER Evaluation Committee because of the formers seriousness and opportunity to improve and the latter for several reasons, such as it being a new Focus Area and unique to the 2021 CLER Report. These findings and themes will be discussed along with each pertinent Focus Area: for example, patient safety has two applicable themes, its two findings from the CLER Evaluation Committee, and its various detailed findings; therefore, when patient safety is discussed, all three of those groupings will be showcased; although often the detailed findings reinforce the selected findings presented by the CLER Evaluation Committee. Other CLER Focus Areas, such as care transitions, have no applicable themes and were not further evaluated by the CLER Evaluation Committee; therefore, the discussion of these Focus Areas will only be focused upon their detailed findings.

Beginning with the various patient safety findings, “[the CLER Report] highlights trends in patient safety that reflect persistent challenges” (p. 95). The following are the themes and findings from the CLER Evaluation Committee (and can be found throughout pages 27-36 of the CLER Report):

Theme #1: Clinical learning environments continue to face significant challenges in changing their health systems at the speed and magnitude needed for sustained improvements in inpatient care. There are a few clinical learning environments in which executive leadership effectively engages the GME community in the design of solutions to address these challenges.

Theme #2: In general, clinical learning environments do not appear to engage all their residents and fellows in their organization’s efforts to design, evaluate, and improve patient safety and health care quality, including health care disparities

**This theme is also relevant to health care quality and will be discussed during that Focus Area as well**

Patient Safety Finding #1: In general, residents, fellows, and nurses lacked clarity and awareness of the range of reportable patient safety events. When queried, residents, fellows, and nurses also appeared to vary in their understanding of how the clinical learning environments used the reporting of adverse events and near misses/close calls to improve systems of care.

Patient Safety Finding #2: Across clinical learning environments, a limited number of residents, fellows, and faculty members participated in interprofessional, interdisciplinary, systems-based improvement efforts, such as patient safety event reviews and analyses

The majority of these themes and findings focus upon limited engagement for CLE faculty and trainees in systemic efforts to improve patient safety: Theme #1 illustrates that a limited number of CLE leadership engage with the GME community to improve patient safety; residents/fellows are not engaged in systemic efforts to improve patient safety and quality in Theme #2, and Patient Safety Finding #2 captures a similar notion that limited participation in organizational efforts has been a common occurrence in CLEs. This lack of engagement can be seen from the detailed findings, as the CLER Report stated that residents and fellows do not regularly conduct standardized time-outs prior to performing procedures (p. 48), had insufficient knowledge of fundamental safety principles and methods (p. 49) and that CLEs commonly did not gauge the success of resident and fellow participation in patient safety event investigations (p. 49). Similarly, Patient Safety Finding #1, which focused upon a lack of reporting and its understanding, can be seen specifically from the detailed findings as well: fellows and nurses commonly lacked the knowledge of the range of reportable events (p. 45), did not commonly report or recognize “near misses/close calls, unsafe conditions, events without harm, unexpected deteriorations, or known procedural complications that occurred as reportable patient safety events;” however, they did regularly report sentinel events, such as medication errors (p. 46). Regarding patient safety challenges that have been brought about by CLE administration, they did not set goals for their residents and fellows on the recognition and reporting of adverse events (p. 49), and there was no standard, but a variation, in CLE “processes for reviewing and prioritizing reported patient safety events or patient safety event reports” (p. 48). In general, across the nation's CLEs, the “format and process of investigating patient safety events varied both across and within CLEs” (p. 50). The lack of engagement and reporting challenges have no doubt been exacerbated by this lack of standardized processes.

Due to this lack of engagement and challenges of reporting, “[t]hese findings reflect that CLEs often find it challenging to demonstrate to the clinical care team (including GME learners) that there were sustainable improvements that resulted from analyses of patient safety event reports” (p. 37). The CLER Report has cited that resident/fellow engagement in patient safety has proved challenging because of the different length and span of GME programs compared to the immediacy of CLEs to provide optimal care (p. 95). While GME programs can span up to 7 years—such as neurosurgery—CLEs have much less time to enact longstanding patient safety initiatives with residents and fellows; thus, engagement is hindered. To better align these two parties, the CLER Program will encourage the GME program and CLE leadership to work together to improve patient safety success (p. 95).

Moving forward with the next Focus Area, the CLER Evaluation Committee chose to specifically highlight, well-being had one applicable theme and five findings from the committee along with the Focus Area’s detailed findings. One could reason that well-being presented numerous key findings from the CLER Evaluation Committee because “[t]his report is the first comprehensive assessment of the ways in which health care organizations serving as CLEs are addressing this important issue” (p. 7). The applicable themes and committee findings for well-being are as follows (and can be found throughout pages 31-40 in the CLER Report):

Theme #3: In addressing well-being, many clinical learning environments are focused on individual responsibility and resilience. Few clinical learning environments appeared to address systems-based factors that adversely impact the well-being of the clinical care team and the safety and quality of patient care.

Well-Being Finding #1: A limited number of clinical learning environments appeared to have a formal strategy to promote, improve, and sustain the well-being of the clinical care team to ensure safe patient care

Well-Being Finding #2: Across many clinical learning environments, efforts to address well-being appeared to focus on individual resilience and wellness with an emphasis on physical and mental health (e.g., nutrition, exercise, gym membership, meditation) rather than systems-based solutions to improve the well-being of the clinical care team

Well-Being Finding #3: Across many clinical learning environments, when well-being efforts existed, they appeared to be siloed and initiated by individual programs, professional groups, service lines, or units with separate activities for residents and fellows

Well-Being Finding #4: Across clinical learning environments, members of the clinical care team reported that burnout among faculty members and nurses was more prevalent than other members of the clinical care team. Burnout was reported among residents and fellows; it was less prevalent compared to faculty members and nurses.

Well-Being Finding #5: A limited number of clinical learning environments appeared to have a systematic approach to preventing, recognizing, and effectively mitigating burnout among physicians. When clinical learning environments were engaged in efforts to address burnout, many were at varying stages of implementing solutions. It was uncommon for clinical learning environments to have assessed the effectiveness of these efforts.

The majority of these themes and findings (barring Well-Being Finding #4) highlight the lack of strategy and system-based efforts that hinder the well-being of CLE faculty and trainees, and this point is reiterated throughout the CLER Report’s detailed findings for well-being (p.65). This is perhaps explained by Well-Being Finding #3 illustrates that many well-being efforts are not centralized and were “siloed and initiated by individual programs, professional groups, service lines, or units with separate activities for residents and fellows.” If these well-being initiatives became more centralized to the CLE itself, strategic, system-based initiatives would naturally emerge. This is echoed in the CLER Reports analysis of the report itself, “[w]ell-being, workforce engagement, and the culture of safety are strongly correlated, so efforts to improve in these areas need to be integrated rather than isolated within individual professional education programs” (p. 96). Moving forward, Well-Being Finding #4 depicts that faculty members and nurses experienced more burnout than residents and fellows. At least in regard to the faculty members, this prevalence of burnout is no doubt correlated with the increased strain supervision and administration place on them. Elaborated below, supervision itself has been paved with challenges throughout the CLER Report as well, which can potentially showcase why faculty members experience burnout more frequently than residents.

For the CLER Focus Area of supervision, the CLER Report identified difficulties to supervise properly, inadequate supervision, and environments where residents/fellows were hesitant to request supervision. Regarding the difficulties to supervise—which can relate to what has previously been said about increased burnout among faculty members when compared to residents—, it was common for physicians to mention the difficulties of supervising trainees during evenings, weekends, and during times where there is a high patient volume (p. 62). Along with this, many program directors were concerned with the challenge of insufficient supervision (p. 62), which could further the strain and pressure placed among faculty members. Challenges in supervision existed from the perspective of the residents and fellows as well: “31.7% [of residents and fellows] reported that while in training at the CLE, they had been placed in a situation or witnessed . . . a situation where they believed supervision was inadequate” (p. 61),  and 48.7% of these trainees reported that attending faculty have made them feel uncomfortable if they requested help with their clinical responsibilities (p. 62). Perhaps in light of this, many CLEs had an environment where residents and fellows were hesitant to request help and supervision from faculty (p. 62). In short, addressing the challenges that have presented themselves in the CLER Report will be of utmost priority as the Focus Area can be intrinsically connected to improvements to other Focus Areas as well, especially to care transitions.

The next CLER Focus Area is care transitions, and among the CLER Report, there were specific instances where the challenges of the Focus Area were intimately connected to supervision: for two examples, 43.7% of residents reported that supervision rarely occurred during their shift-to-shift hand-off process (p. 58), and the report identified that a lack of consistent supervision and proactive monitoring posed challenges to care transitions (pp. 59-60). Enhanced supervision will prove vital to mitigating the challenges in care transitions and multiple other Focus Areas as “residents, fellows, nurses, and other clinical staff members identified many transitions they believed posed vulnerabilities in patient safety,” and residents and fellows commonly reported that communications during these transitions were incomplete or inaccurate (p. 57). Enhancing supervision will be a prominent factor in addressing the challenges of the care transition.

Moving forward to health care quality, while the Focus Area has improved recently, the latest CLER Report cycle has illustrated minimal changes or improvement (p. 92). The majority of these areas of improvement are related to Quality Improvement (QI). Health care disparities are also intimately associated with this Focus Area and can be improved from QI initiatives; however, few residents “reported that they had participated in a QI project focused on eliminating health care disparities at their clinical site” (p. 56). Therefore, while there are many areas to discuss in regard to improving health care quality, improvements in QI and their engagement within them are perhaps the prominent pathways towards major improvement. The CLER Report’s detailed findings included the following regarding QI:

  • Residents and fellows were not commonly involved in QI strategic planning (p. 51)
  • Residents and fellows did not commonly participate in QI committees, as the expectations were unclear, and the committees lacked structure (p. 51)
  • QI projects did not regularly align with their CLE’s priorities (p. 53)
  • Residents and fellows could not commonly describe QI projects that were interprofessional team-based (p. 53)

These general improvements that can be made relate to what was depicted in Theme #2, that residents and fellows were not commonly engaged with organizational efforts to enhance patient safety and health care quality. Part of this lack of engagement can be seen and addressed by the improvements to be made towards QI. The CLER Report recommends that improving QI could be to follow “the well-accepted model of quality outlined by Donabedian in his seminal work on quality improvement, with attention to structure, process and outcomes” (p. 96). Emphasizing structure and processes would no doubt improve how residents and fellows could interact with QI more intimately.

The last CLER Focus Area that the CLER Report discusses is professionalism. This Focus Area involves integrity, honesty, and reporting. Overall, the vast majority of CLEs reported professional environments per group interviews that were conducted with residents and fellows during the CLER site visit (p. 70). More so, it was reported that CLEs provide a supportive environment that does not punish those who come forward with concerns (p. 93). Although the CLER Report nonetheless identified challenges in honesty, reporting, and integrity: around 33% of residents and fellows reported that “they had documented a history or physical finding in a patient medical record that they did not personally elicit” (p. 93) and 15% reported they had felt pressured at their CLE to compromise their honesty and integrity (p. 61). Along with this, residents and fellows were frequently unaware of mechanisms and resources to utilize or appeal to when unprofessional acts occur around them (p. 73). While a majority of the CLEs were said to have professional environments, the CLER Report has made clear the challenges that persist in light of this.

The 2021 CLER Report has shone a bright light on challenges that many CLEs face when pursuing the six CLER Focus Areas. In total, much of the challenges that each Focus Area faces can be applicable to multiple Focus Areas: this could be seen from the connections with supervision or the strategic initiatives that are lacking for patient safety. Due to the challenges at hand, engaging the GME community within health systems and specific organizations and addressing system-based influences will no doubt be a priority of CLEs and of the CLER Program; the CLER Report has brought these major themes to light and reinforced them through the detailed findings of each focus area.

Work Cited

Kuhn, Catherine M., MD et al. “CLER National Report of Findings 2021.” ACGME, October 2021, 2021clernationalreportoffindings.pdf (acgme.org).

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