ACGME Accreditation Council for Graduate Medical Education

Clinical Learning Environment Review (CLER) Program

CLER Program Overview

As a component of its next accreditation system, the ACGME has established the CLER program to assess the graduate medical education (GME) learning environment of each sponsoring institution and its participating sites. CLER emphasizes the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care, a key dimension of the 2011 ACGME Common Program Requirements. The intent of CLER is “to generate national data on program and institutional attributes that have a salutary effect on quality and safety in settings where residents learn and on the quality of care rendered after graduation.”1

CLER provides frequent on-site sampling of the learning environment that will:

  • increase the educational emphasis on patient safety demanded by the public; and,
  • provide opportunity for sponsoring institutions to demonstrate leadership in patient safety, quality improvement, and reduction in health care disparities

The CLER program’s ultimate goal is to move from a major targeted focus on duty hours to that of broader focus on the GME learning environment and how it can deliver both high-quality physicians and higher quality, safer, patient care. In its initial phase, CLER data will not be used in accreditation decisions by the Institutional Review Committee (IRC).

CLER consists of three related activities:

  • The CLER site visit program is used solely for providing feedback, learning, and helping to establish baselines for sponsoring institutions, the Evaluation Committee, and the IRC. The first cycle of visit findings will result in dissemination of salutary practices by the Evaluation Committee.
  • The CLER Evaluation Committee includes a broad cross-section of individuals with expertise related to the aim of the CLER program. The Committee provides input to the design and implementation of CLER site visit activities and conducts evaluation review of sponsoring institutions that are visited during each cycle.
  • The ACGME recognizes the great interest by sponsoring institutions to support faculty development in those areas on which the CLER program will focus (e.g., patient safety, health care quality, transitions of care, etc.). Therefore, as part of the CLER program, the ACGME will develop a program to support faculty development.

CLER assesses sponsoring institutions in the following six focus areas:

  • Patient Safety – including opportunities for residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care.
  • Quality Improvement – including how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes.
  • Transitions in Care – including how sponsoring institutions demonstrate effective standardization and oversight of transitions of care.
  • Supervision – including how sponsoring institutions maintain and oversee policies of supervision concordant with ACGME requirements in an environment at both the institutional and program level that assures the absence of retribution.
  • Duty Hours Oversight, Fatigue Management and Mitigation – including how sponsoring institutions: (i) demonstrate effective and meaningful oversight of duty hours across all residency programs institution-wide; (ii) design systems and provide settings that facilitate fatigue management and mitigation; and (iii) provide effective education of faculty members and residents in sleep, fatigue recognition, and fatigue mitigation.
  • Professionalism—with regard to how sponsoring institutions educate for professionalism, monitor behavior on the part of residents and faculty and respond to issues concerning: (i) accurate reporting of program information; (ii) integrity in fulfilling educational and professional responsibilities; and (iii) veracity in scholarly pursuits.

The initial round of CLER evaluations will seek answers to the following central questions:

  • Who and what form the infrastructure of a Sponsoring Institution’s clinical learning environment? What organizational structures and administrative and clinical processes do the SI and its major participating sites have in place to support GME learning in each of the six focus areas?
  • How integrated is the GME leadership and faculty within the SI’s current clinical learning environment infrastructure? What is the role of GME leadership and faculty to support resident and fellow learning in each of the six areas?
  • How engaged are the residents and fellows in using the SI’s current clinical learning environment infrastructure? How comprehensive is the involvement of residents and fellows in using these structures and processes to support their learning in each of the six areas?
  • How does the SI determine the success of its efforts to integrate GME into the quality infrastructure? From the perspective of the SI and its major participating sites, what are the measures of success in using this infrastructure and what was the level of success?
  • What areas have the Sponsoring Institution identified as opportunities for improvement? From the perspective of the SI and its major participating sites (if different), what are seen as the opportunities for improving the quality and value of the current clinical learning environment infrastructure to support the six focus areas?

1Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system--rationale and benefits. N Engl J Med. 2012;366(11):1051-1056. [Epub 2012 Feb 22.] 06/10/2012 Ver. 1.0