Since 2012 the Clinical Learning Environment Review (CLER) Program has provided Accreditation Council for Graduate Medical Education (ACGME)-accredited Sponsoring Institutions with formative feedback to clinical sites that serve as clinical learning environments (CLEs) for resident and fellow physicians. The program’s goal has been to provide information that will help CLE executive leaders and graduate medical education (GME) leaders identify opportunities for improvement in the CLER Focus Areas to optimize both learning and patient care. The CLER National Reports of Findings1-3 have demonstrated that the process of providing formative feedback has led to improvements in the Focus Areas (such as improved resident physician reporting of patient safety events) and identified challenges in the nation’s CLEs that were not previously evident prior to initiating the CLER Program’s structured, purposeful assessment of the CLE.To date, the ACGME’s CLER Program has achieved several important outcomes. The program has: (1) stimulated new connections between GME leaders and the executive leaders of their CLEs and health systems; (2) improved resident and fellow engagement in the CLER Focus Areas, most notably in patient safety; (3) published periodic reports on CLER findings and trends that provide a national perspective; and (4) informed ACGME accreditation relevant to the CLER Focus Areas through inputs to the Common Program Requirements and the Institutional Requirements.The CLER Program is now well positioned to expand its efforts to accelerate improvement and respond to the needs of the GME/CLE community. Throughout the 4-plus cycles of CLER visits to date, many designated institutional officials (DIOs) have noted that the CLER Program is designed to visit a single clinical site and have expressed a desire to engage the executive leaders of other CLEs within their Sponsoring Institution. DIOs have also expressed interest in having a way to conduct their own assessments of their CLEs. Additionally, CLE executive leaders and GME leaders continue to ask the CLER Program to share best practices to address the CLER Focus Areas as they seek to learn from the successes of others.DIOs frequently note the CLER Program’s site visits and outreach initiatives have prompted closer interactions with their CLE’s executive leaders and resulted in better alignment with the CLE’s priorities. The CLER Pursuing Excellence initiative4 highlighted the importance and substantive value of enhancing CLE-GME integration. The GME leaders participating in this initiative moved beyond their usual scope of overseeing medical education to contribute to key aspects of their organization’s health care delivery strategy. The initiative demonstrated that purposeful efforts to integrate CLE and GME strategic goals advance the CLE’s overall mission to grow value-based care, drive clinical quality, and improve patient experience.Considering the experience and growing needs of the GME community, there is opportunity to evolve and metamorphize the CLER Program into a more comprehensive program with multiple approaches to improve the learning environment and accelerate CLE-GME integration.The redesign of the CLER Program into a new CLE Program will build upon the successful efforts of the CLER site visit program, the CLER Pursuing Excellence initiative, and other models of collaborative engagement and learning. In its redesign, the CLER Program will expand to offer GME and CLE executive leaders new tools, resources, and opportunities to accelerate their efforts to optimize the CLE.The new CLE Program is designed to have 4 main components: (1) a national CLER site visit program; (2) a CLE Toolkit for Formative Assessment; (3) a CLE Quadruple Aim initiative; and (4) other CLE resources. The new CLE Program will address the need for innovative efforts that can expand the program’s reach. This will require a broadening of the branding and terminology formerly attached to “CLER” to recognize that “Reviews” conducted via CLER site visits will be one of several components of the expanded CLE activities and resources. Therefore, the program’s name will change from CLER Program to CLE Program.CLER site visits will continue to be the core component of the program, delivering high-fidelity formative assessment and feedback to CLE and GME leaders and aggregate national data to inform future ACGME accreditation requirements.Since the inception of the CLER Program, the number of ACGME-accredited Sponsoring Institutions has grown considerably, from several hundred in 2012 to more than 870 in 2023. To address this growth, the CLER site visit program has moved to a sampling approach to identify Sponsoring Institutions to visit during each cycle—targeting approximately 300 Sponsoring Institutions per 2-year cycle. Samples are randomly generated based on certain strata (eg, geographic location, number of ACGME-accredited programs) at the start of each cycle. The CLER Program will continue to ensure the samples are proportionally representative of all Sponsoring Institutions each cycle.The CLER site visit program will also continue to develop and implement subprotocols to augment CLER site visits.The second component of the new CLE Program is a resource called the CLE Toolkit for Formative Assessment, and use of the toolkit is voluntary. The toolkit is a direct response to the GME community’s requests for the CLER Program to expand its reach to other CLEs. The CLER Program often receives requests to visit sites other than the site traditionally designated. The ACGME Data Resource Book5 noted a total of 8640 unique participating sites to which residents and fellows rotated during the 2021-2022 academic year—a volume that far exceeds the CLER Program’s capacity to address. A CLE Toolkit for Formative Assessment can provide the GME community with a structured and standardized approach to self-administered assessment that can be used across all CLEs within a Sponsoring Institution.Also, while CLER site visits provide a comprehensive and in-depth assessment of the CLE, these visits are periodic snapshots. The toolkit can help CLE and GME leaders maintain the momentum for improvement and innovation in their CLEs between CLER site visits.The toolkit will consist of modular components designed to: provide a process to identify existing gaps and areas for improvement, present comparative data within and across CLEs (eg, benchmarking), including multiple participating sites that are part of a single Sponsoring Institution, and allow for assessment of existing CLE improvement efforts and innovations.The information gathered can promote reflection and conversations among CLE executive leaders, GME leaders, and clinical care team members to facilitate ongoing learning and improvements in the CLER Focus Areas.The CLE Program will employ a systematic approach to the toolkit’s development and dissemination to ensure each module yields valid and reliable information. The first module will address the CLER Focus Area of patient safety. Key steps in the developmental process include: (1) conducting focus groups with key stakeholders; (2) recruiting a small group of Sponsoring Institutions to test the toolkit; (3) conducting multiple rounds of testing to gather input on content, usability, and feasibility; and (4) designing educational sessions to provide guidance and support on how to locally administer toolkit modules.While the first module will focus on patient safety, the same process for development and dissemination will be employed when developing modules in the other CLER Focus Areas.Additionally, the CLE Toolkit for Formative Assessment will provide comparative data across CLEs for benchmarking. The ACGME will collect de-identified data on selected measures from each Sponsoring Institution using the toolkit.The third component of the new CLE Program speaks to the CLE and GME community’s desire to identify successful approaches to address challenges and opportunities for improvement by inviting them to join a learning collaborative to focus on the Quadruple Aim. This new initiative will be directed at strengthening partnerships between GME and CLE executive leaders to advance the Quadruple Aim of simultaneously improving patient outcomes, enhancing patient experience, improving health care practitioner well-being, and reducing cost of care (Sponsoring Institutions may expand to address the Quintuple Aim, which includes advancing health equity).6The CLE Quadruple Aim initiative will tap into the National Learning Community of Sponsoring Institutions to identify and work with GME and CLE executive leaders who are motivated to address the Sponsoring Institution 2025 pillars of Demonstrating Commitment to Excellence in Patient Care and Optimizing Health Systems for Learning (see Figure) and jointly solve for CLE systems-based challenges.This initiative builds upon a number of successful models from within and outside the ACGME.7,8 Between 2016 and 2021, for example, the CLER Program’s Pursuing Excellence initiative conducted a series of collaboratives designed to promote transformative improvement in the CLEs of ACGME-accredited Sponsoring Institutions.9This initiative is different from many GME initiatives in that the challenges the participants choose to address will originate from the executive leaders of the CLEs and subsequently leverage GME insights to jointly design and test new approaches to solving for them.For each team participating in the CLE Quadruple Aim initiative, the CLE’s executive leaders will be asked to identify a current challenge that:can benefit from GME insights and collaboration;identifies specific, measurable, achievable, relevant, and time-bound (SMART) goals that incorporate each of the elements of the Quadruple Aim, including how the intervention will impact the well-being of the clinical care team;is scoped such that the improvement activities fit a 12-month time frame; andis linked to 1 or more CLER Pathways properties.The CLE Quadruple Aim initiative will start with a small cohort of 8 to 10 teams that volunteer through an ACGME call for interested participants. The initial group will start what will become a continuous series of collaborative learning cycles in a 2 + 12 + 1-month time frame, with new cohorts of CLE teams entering each cycle. At the launch of each cycle, the new cohort will meet in person. Subsequent meetings will occur remotely via Zoom frequently enough to keep the work on track.The 2 + 12 + 1 time frame includes 2 months of prework (eg, teams refining the scope and goals of their activity) and 12 months of “run time” (rapid-cycle tests of change and approximately one month to consolidate knowledge gained and widely share lessons learned). At the conclusion of each cycle, the teams will post a summary of their efforts that details successful approaches and lessons learned on a designated site at which the information will be publicly accessible to the entire CLE/GME community. The initiative will provide a mechanism to sustain the community of past participants for regular peer-to-peer support through remote group check-in meetings 2 to 4 times a year.CLE Program staff will serve as conveners, facilitators, and coaches. In these roles, they will assist teams to identify and engage new stakeholders, foster peer-to-peer dialogue and problem solving, and guide team member engagement.Each team will designate a local lead “owner” (eg, DIO or designee such as associate DIO, CLER director, etc) and will include a mix of GME and CLE executive leaders plus residents, fellows, and other members of the clinical care team as appropriate for their topic.In particular, the initiative will seek to foster CLE/GME relationships that elevate GME leaders so they are increasingly engaged as key assets in design, testing, implementation, and evaluation of CLE initiatives.In the fourth component of the new CLE Program, staff will curate a collection of resources to be housed by the ACGME and made available to the CLE/GME community. Resources may include but are not limited to:summaries of successful practices and lessons learned from using the CLE Toolkit for Formative Assessment;summaries of successful practices and lessons learned from participating in the CLE Quadruple Aim initiative;resources developed by the ACGME as part of outreach efforts resulting from the National Learning Community of Sponsoring Institutions; andresources, tools, and successful practices crowdsourced from the CLE/GME community.CLE Program staff will also continue to provide other opportunities for collaboration such as webinars and workshops.The goal of redesigning the CLER Program is to accelerate efforts to optimize CLEs for both learners and patients. This redesign involves 4 components as outlined above:Component 1 continues to give clinical sites, the nation, and the ACGME a high-fidelity assessment of progress in the CLER Focus Areas.Component 2 allows the ACGME to build upon the evidence base created and maintained by CLER site visits by increasing capacity among GME and CLE executive leaders to assess their own CLEs.Component 3 strengthens the partnerships between GME and CLE executive leaders such that GME takes an active lead role in CLE efforts to design, test, implement, and evaluate systems-based changes to patient care that further the Quadruple Aim.Component 4 provides resources to all members of the CLE/GME community, serving as a vehicle to disseminate successful practices and lessons learned.With more than 4 cycles of experience and a decade of insightful feedback from DIOs, chief executive officers, and other CLE executives to draw upon, the CLER Program is poised to implement its innovative redesign—and, in the process, foster new partnerships to optimize patient care.The authors would like to acknowledge all of the members of the CLER Program staff both for their contributions to the working groups that shaped the various components of the CLER Program redesign and for their dedication to serving the GME and CLE communities in their efforts to optimize learning and patient care: Isabelle Bourgeois, MPA; Robert Casanova, MD, MHPE; Marian D. Damewood, MD, FACOG; Kevin Dellsperger, MD, PhD; Robin Dibner, MD; Brenda Moss Feinberg, ELS; Staci A. Fischer, MD, FACP, FIDSA; Paula Hensley, MPH; Joshua Miron, MA; Wardah Mohammad, MA; Douglas E. Paull, MD, MS, FACS, FCCP, CHSE, CPPS; Sandra Rials, MS; Ana L. Sainz; Melissa Schori, MD, FACP, MBA, CPPS; Jordan Stein, PhD; Hongling Sun, PhD; Elizabeth Wedemeyer, MD; Esther Woods; Martha S. Wright, MD, Med; James R. Zaidan, MD, MBA; and Jose Zayas, DO, FAAP.The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its Review Committees. The decision to publish the article is made by the ACGME.

In the closing days of 2019, the world found itself bracing for the unknown impact of a newly discovered human illness now known as COVID-19. For nearly 3 years, this virus has caused a pandemic that has reached every corner of the globe.As the COVID-19 pandemic stretched from months to years, the Accreditation Council for Graduate Medical Education (ACGME) strove to understand the impact of this virus on the US health care system and, more specifically, on graduate medical education (GME). The Clinical Learning Environment Review (CLER) Program was mobilized to assist the ACGME and the community as we strove to develop a better understanding of the sustained impact of the pandemic on the clinical learning environments (CLEs) of ACGME-accredited Sponsoring Institutions. To achieve this goal, the CLER team developed and implemented a unique protocol that focused on identifying any impact of the COVID-19 pandemic that would likely persist for at least 2 years.The CLER National Report of Findings 2022: The COVID-19 Pandemic and Its Impact on the Clinical Learning Environment presents information gleaned from this specially commissioned set of site visits to 287 hospitals, medical centers, and other health care environments that serve as CLEs for ACGME-accredited Sponsoring Institutions. The findings represent a stratified random sample of the more than 750 eligible ACGME-accredited Sponsoring Institutions. As per other CLER protocols, site visits addressed only one CLE for each Sponsoring Institution in the sample. The visits were conducted between October 2020 and April 2022.The COVID-19 pandemic has had a dynamic and unpredictable impact on society and health care environments. The site visits that are the basis of this report were conducted through pandemic time periods that included the early phases. Specifically, the visits covered (1) the time period prior to vaccine availability and prior to the emergence of a shared set of practices for treatment of the severely ill; (2) the time period during which vaccines and boosters were introduced and treatment of severely ill patients was becoming more standardized; and (3) the time period during which Delta and Omicron variants emerged (and their consequential impacts). The site visits were completed just before oral treatment agents were becoming widely available. Therefore, these findings must be viewed from the lens of CLEs that recently navigated these challenging times. Efforts were made to avoid visiting CLEs during acute surges of COVID-19 in their communities; as a result, it is difficult to fully understand how experiences with managing the pandemic's acute phases may have shaped their perceptions of the likely impact over the next 2 years.With these challenges in mind, it is noteworthy that, collectively, these site visits allowed us to identify several important, and likely enduring, findings that warrant the attention of the GME community and CLE executive leaders. The full report identifies 8 overarching themes as listed below:Each theme is described in detail in the body of the report, and each has an important bearing on the future of health care and GME. Collectively, these themes represent an opportunity for reflection on what was done well, as well as learning and improvement that will allow CLEs to face the aftermath of the pandemic and to prepare for the next global health care challenge.As CLEs emerge from what everyone hopes have been the worst phases of the COVID-19 pandemic, it is likely that many hospitals, medical centers, and health care systems will endeavor to find a way back to some version of "normal" based on pre-pandemic health care and GME routines. However, it is important to recognize that the pandemic has created many opportunities and avenues to harvest and apply new approaches to learning and clinical practice. One example is the dramatic increase in the use of remote technology to facilitate clinical care and learning experiences. Many successful practices that emerged from use of remote technology can serve as a basis for rapid evolution in approaches to patient care and education. Similarly, major workforce disruptions have led to many innovations in how clinical care teams interact with each other, such as accelerated use of text or video communications, which potentially can streamline clinical care and provide new opportunities for learning. These advances in remote and asynchronous learning and clinical care must also be explored for their impact on community, group learning, culture, and identity formation of learners.Additionally, the pandemic painfully exposed long-standing disparities in health care. This exposure serves as a clarion call to prioritize health care equity as a principal issue in US health care policy and practice, and it requires the explicit attention of the leadership and membership of health care systems and systems of education at all levels of the continuum for all professions.This report also provides insights in the section on detailed findings and the accompanying appendices. For example, the report notes that 72.6% of residents and fellows interviewed reported changes in patient care processes at their clinical site, as a result of the pandemic, that they viewed as sustained improvements in health care. The detailed findings also note that 52.3% of residents and fellows interviewed who were postgraduate year 3 and above reported participating in an interprofessional investigation of a patient safety event.The appendices also contain several notable findings that reflect gender differences. For example, for the clinical sites visited, female residents and fellows were more likely than males to report encountering a physician (attending physician or consultant) who made them feel uncomfortable when requesting assistance (48.0% vs 39.1%, respectively, P<.001). Females were also more likely than males to report issues regarding supervision of consults conducted by residents and fellows as a result of the pandemic (15.8% vs 11.0%, respectively, P<.001). Female residents and fellows were less likely than males to report that their clinical sites had services and resources to help them manage emotionally stressful patient care situations resulting from the pandemic (76.2% vs 82.8%, respectively, P<.001). These findings suggest important gender-specific challenges within CLEs related to diversity, equity, and inclusion that warrant further consideration.In addition to the findings summarized in this report, the unique design of this specially commissioned set of CLER site visits provided the CLER Program with new insights resulting from innovations in how it conducts CLER visits. Examples of innovations included conducting group interviews via remote technology and reconfiguring the opening and closing meetings with executive leadership to be more conversational. Additionally, the CLER Program conducted the protocol on a sample of Sponsoring Institutions. Insights gained from these recent changes have been incorporated into the next CLER protocol that is currently underway.The year ahead will be an exciting one for the CLER Program as it engages in a process of strategic transformation and metamorphosis. Throughout this transformation, CLER site visits will continue to serve as the foundation of the CLER Program. These visits provide a critically important evidence base for formative learning for the ACGME and the GME community, including their hospitals, medical centers, and health care systems.The ACGME Department of Sponsoring Institutions and Clinical Learning Environment Programs, which houses the CLER Program, also will develop new programmatic activities designed to support GME leaders in enhancing their CLEs through collaborative social learning networks and sharing of multimedia resources and toolkits that can amplify successful practices tested in the GME/CLE community. The department is also in the process of designing a new formative learning resource for the nation's Sponsoring Institutions that identifies CLE outcomes that align with the Quadruple Aim1,2 and support high-quality GME and patient care.As US health care systems and the GME community emerge from the acute phases of the COVID-19 pandemic, there are new opportunities to take stock of the many lessons learned from its impact. The CLER Program trusts that the findings from this special site visit protocol will provide part of the road map on how to focus collective efforts toward harvesting some of the successful innovations in patient care delivery and GME that have emerged from the challenges posed by the pandemic.

Since 2012, the Accreditation Council for Graduate Medical Education's (ACGME's) Clinical Learning Environment Review (CLER) Program has been conducting site visits to hospitals, medical centers, and ambulatory sites that serve as clinical learning environments (CLEs) for resident and fellow physicians in training.1 The CLER program provides each CLE it visits with formative feedback on cross-cutting areas of focus, including patient safety and health care quality. At the end of each cycle of visits, the CLER program provides a national report of findings, publishing its first National Report in 2016 and its second in 2018. The reports noted that clinical learning environments vary in their approach to and capacity for addressing patient safety and health care quality and the degree to which they engage residents and fellows in these areas.2,3 These reports also noted that clinical learning environments vary in the extent to which they invest in continually educating, training, and integrating faculty members and program directors in the areas of health care quality, patient safety, and other systems-based initiatives.2,3The CLER National Report 2018 showed CLEs varied widely in the percentage of resident and fellow physicians who experienced a patient safety event and also submitted an event report through the organization's reporting system, with a median of just 50%, revealing much room for improvement. This report also highlighted the importance of going beyond equipping residents and fellows with knowledge of patient safety and emphasized the need for efforts that inspire them to engage with their CLE to take action.In 2018, the ACGME's Department of Research, Milestone Development, and Evaluation released Systems-Based Practice Milestones for Patient Safety and Quality Improvement to highlight developmental markers for engaging residents and fellows in addressing patient safety and health care quality as part of their comprehensive training.4,5 At the same time, the ACGME also recognized a growing need for faculty development in these areas. The ACGME's Department of Education conducted a faculty needs assessment that revealed the need for widespread faculty development in the areas of patient safety and health care quality. Further analysis suggested that sponsoring institutions and residency and fellowship programs in particular lacked faculty who can mentor and guide residents and fellows in experiential learning in these areas.Between 2016 and 2021, the CLER Program's Pursuing Excellence Initiative6 facilitated several learning collaboratives that included efforts to identify new educational models and build capacity to engage residents and fellows in addressing patient safety and quality.7,8 These efforts, aimed at the level of the sponsoring institution and CLE, were designed to recognize the importance of building partnerships between graduate medical education (GME) and CLE leaders in patient safety and quality. In particular, the Pursuing Excellence Pathways Leaders Collaborative embraced a framework put forth by the National Collaborative for Improving the Clinical Learning Environment9 that emphasized engaging learners in addressing patient safety as early as possible in their training.From the confluence of these efforts emerged the realization that GME and CLEs viewed resident and fellow engagement in patient safety and health care quality from 2 different perspectives: (1) resident and fellow competency as reflected through milestone levels of progression, and (2) CLE patient care needs (Figure 1). From the educator's perspective, the milestones for safety and quality could comfortably span the duration of training, with higher levels of achievement happening toward the end of the training experience. However, from the CLE's perspective, patient care necessitates introducing these developmental markers much earlier in training so that students, residents, and fellows in all health care professions can contribute meaningfully to the CLE's efforts to ensure safe, high-quality patient care. Engaging learners early in training on patient safety and quality practices may also better ensure continued integration into practice after training is completed.To close the gap regarding educational needs and expectations, and also to address the need for faculty development, the Education Committee of the ACGME Board of Directors approved a new initiative in June 2018 with the following aim:"Design, pilot, and implement a national learning network for program directors and their faculty to rapidly advance their capacity to develop, model, and evaluate resident and fellow engagement in patient safety/quality improvement."In time, the initiative came to be called the Program Directors Patient Safety and Quality (PDPQ) Educators Network.In designing this new initiative, the ACGME sought to utilize models of learning and support with proven sustainability and spread. With over 12 000 ACGME-accredited residency and fellowship programs in the United States, the model needed to apply to a wide range of specialties, be feasible in a variety of contexts, and pose minimal financial burden. To further this work, the ACGME sought 2 key partners.The first of these partnering organizations was the Organization of Program Director Associations (OPDA), convened by the Council of Medical Specialty Societies (CMSS). The ACGME recognized that faculty development largely rests within specialty societies and program director associations. These organizations have longstanding experience in offering activities and programming to help GME leaders stay current on educational content within both their specialties and the broader changing environment of health care. Another important factor in partnering with CMSS/OPDA was the recognition that, while the overall concepts of patient safety and quality improvement cross all specialties, the necessary experiential learning most often happens at the specialty-specific level. In CMSS/OPDA, the ACGME had a partner with access to GME leaders in patient safety and quality that could make these concepts relatable to residents and fellows on a specialty-specific basis. This partner also could potentially assume a greater role in fostering sustainability and spread among program director associations.The second partnering organization in developing this new initiative was Project ECHO of the University of New Mexico Health Sciences Center, a tele-mentoring model that uses technology to share successful practices through case-based learning and monitoring of national and international outcomes.10,11Project ECHO has demonstrated that strong bonds form among participants of various ECHO ventures and are key to Project ECHO's success. Project ECHO noted that, by committing to meeting on a regular basis, the teleconference sessions became more than an exchange of ideas and expertise. They were virtual gatherings that fostered a sense of community and support—attributes that in turn contributed to sustainability and spread. By 2018, Project ECHO had grown significantly across the United States and internationally since its launch 15 years earlier. During that time, most Project ECHO efforts focused on sharing best practices to manage and treat clinical conditions. The PDPQ initiative would uniquely focus on education and use of the Project ECHO model to enhance the development, implementation, and assessment of educational programming to engage residents and fellows in patient safety and quality improvement.In December 2018, the partnering organizations developed and disseminated an invitation to program director associations and their associated specialty societies to apply to join the PDPQ Educators Network. The application included a social contract outlining the expectation for program director associations and specialty societies to support, sustain, and grow the initial efforts of this network at the specialty level.Each applicant organization was asked to nominate a leader in patient safety and quality improvement within their specialty. This individual would participate as a member of the design team to develop a distance learning course for program directors and designated faculty, participate in the initial pilot of the course as a presenter and facilitator, and lead efforts to sustain and build upon the initial work within that specialty. Organizations were also asked to nominate a second individual who was familiar with operational aspects of launching educational initiatives for the program director association or their relevant specialty society.Seven program director associations applied in response to OPDA's invitation. Recognizing that the initial infrastructure of the network could not support all 7 specialties at once, the partnering organizations engaged 4 reviewers external to ACGME and OPDA to assess and prioritize the applications. Neurological surgery, emergency medicine, and internal medicine were selected as the first specialty participants in the network.Early in the initiative, the partnering organizations established 3 levels of oversight: an Executive Team, a Core Team, and a Specialty Advisory Council. The Executive Team, comprising leaders from ACGME and Project ECHO, met weekly to develop an aim statement and to draft and continually update a working project plan. This team was responsible for creating and facilitating agendas for the Core Team and Specialty Advisory Council, coordinating communications, and maintaining a repository of all finalized documents and other materials. The Executive Team was also responsible for maintaining contact with leadership of the ACGME, OPDA, and Project ECHO, as well as other key stakeholders to ensure alignment with other work of these organizations and explore options for sustainability and spread.The Core Team comprised members of the Executive Team, co-leads from each of the specialties, and additional faculty contributing interprofessional perspective and expertise in patient safety and quality improvement education and assessment. One of the first tasks of this team was to conduct a literature review of articles addressing patient safety and quality improvement education of residents, fellows, and faculty members. Building on that background, the team met regularly to develop and prioritize goal statements and learning objectives for program directors and other GME leaders, as well as design a conceptual model for the network launch. This team also developed a course outline and content for a structured component to be delivered during the initial phase of the network and actively participated in its implementation and evaluation.The Specialty Advisory Council, comprising representatives from specialties not selected during the first round, closely followed progress of initial pilot efforts in anticipation of joining the network in a future round. In doing so, they provided the Executive Team with advice and guidance on effective strategies to create, grow, and sustain this national learning network.As noted in the aim approved by the ACGME Board of Directors, the PDPQ Educators Network sought to develop, test, and implement distance learning-based faculty development activities that would inform and support program directors, associate program directors, and faculty members as they mentor and guide residents and fellows in understanding and addressing patient safety and health care quality. A conceptual framework with 2 components emerged (Figure 2):Under the leadership of the specialty-based members of the Core Team, the PDPQ Educators Network recruited 13 specialty-based teams from ACGME-accredited sponsoring institutions across the country to participate in an initial pilot test of the conceptual framework. The teams in turn secured the support of their institutions' GME leaders and patient safety and quality leaders.During the initial pilot of the 6-month series that launched on January 7, 2020, and concluded on June 26, 2020, nearly all participants were retained from start to finish. Since this initial pilot, interest in the PDPQ Educators Network continues to grow within both the original and new specialties that joined in subsequent rounds. During the last several years, 7 specialties have been added, with approximately 100 residency programs participating in the initiative.In designing the PDPQ Educators Network, the Core Team recognized that many residency and fellowship programs have some form of educational programming to teach patient safety and quality improvement, yet programs vary widely in their approaches to and success with engaging learners in these important areas. Nationally, this continues to be identified in CLER reports as an educational and clinical care gap. This initiative is designed to assist program directors in building on whatever base educational programming they have in place at their clinical sites by equipping them with new ways to think about building program capacity, aligning educational and patient care priorities, deepening experiential learning, assessing learner progress, and holistically evaluating their patient safety and quality educational programs. The program is designed as a collaborative learning network, and nearly all its design and implementation reflects peer-based engagement across multiple ACGME specialties (internal medicine, emergency medicine, and family medicine).This pilot launched in the first half of 2020 and held together throughout the most uncertain and difficult times of the COVID-19 pandemic. This continuity demonstrates the value of forming a community of learning. The Core Team is currently analyzing the impact of PDPQ on participating faculty and their institutions and educational programs. These analyses will be detailed in future publications; however, the continued investment of the partnering organizations, program director associations, and specialty societies provides early evidence that learning communities such as these are promising new models that can enhance education and catalyze change.Of note, while the PDPQ pilot focused on patient safety and quality, it potentially provides the community of GME program director associations and their specialty societies with a model that could be replicated with other topics for which there are gaps in educational programming and a need for rapid peer-based learning to address these gaps.In summary, the preliminary experience of the PDPQ Educators Network demonstrated new ways with which to approach several challenges at once by addressing the needs of GME residencies and fellowships to enhance educational programing, expanding faculty capacity, accelerating and deepening resident and fellow learning, and meeting the CLEs' needs to improve safety and quality in patient care. This experience also has the potential to achieve a long-term goal of inspiring future physicians through experiences that engage them in systems-level thinking and practice to optimize patient safety and health care quality, such that they carry patient safety and quality improvement knowledge, skills, and behaviors into their clinical practice throughout their careers.

Since its inception, the Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) Program has sought to create a conversation about how the hospitals, health systems, and other clinical care settings that host ACGME-accredited residency and fellowship programs serve as clinical learning environments (CLEs) for our nation's resident and fellow physicians.1 Over the past 5 years, the CLER national reports have provided the leaders of graduate medical education (GME) and the executive leaders of CLEs with new information aimed at optimizing learning and patient care.2–4From the beginning, the CLER Program has experienced challenges in comprehensively including the operative and procedural areas as part of the site visit protocol. The CLER Program recognized the importance of understanding these key clinical areas—both the implications for patient safety and health care quality5,6 and the implications for how residents and fellows learn in these environments. In its third cycle of visits, the CLER Program implemented a subprotocol in parallel with the regular visit to a sample of 25 of the larger Sponsoring Institutions with ACGME-accredited programs in surgical and anesthesia specialties. The subprotocol specifically addressed the challenges that made it impractical to include the operative and procedural rooms in the regular CLER visit. The main protocol and associated subprotocol explored the 6 focus areas of patient safety, health care quality (including health care disparities), care transitions, supervision, well-being, and professionalism.The teams for these augmented visits were enhanced with 2 to 4 additional CLER Field Representatives with backgrounds in surgery or anesthesiology. The team members responsible for the subprotocol joined the other members of the CLER site visit team for the initial and exit meetings with executive leadership and the meeting with the leaders in patient safety and quality. Aside from these meetings, they focused exclusively on the operative and procedural areas of the clinical site.The subprotocol included scheduled meetings with physician and nursing leaders in surgical and procedural areas and meetings with operating room nurses. However, the majority of the subprotocol team members' time was spent on walking rounds observing the preoperative, operative, and postoperative care units, and talking with various members of surgical and procedural teams.The CLER Program released the first report of findings from the subprotocol in March 2021.7 This report provides an important look at these unique CLEs. As with the larger CLER national reports, the key findings of the subprotocol highlight a mixture of strengths and opportunities for improvement—some unique to the perioperative environment and some that are similar to other places within the CLE. Dr Thomas Nasca, President and Chief Executive Officer of the ACGME, notes in his introduction to the report that the findings are important in that they reveal unexpected attributes of the learning environment that may spur new thinking about opportunities to improve the operative and procedural experiences for residents and fellows. The following findings were highlighted as possible opportunities for future conversations:In addition to these selected findings, the report also includes a rich set of additional findings and related discussions authored by volunteer members of the CLER Evaluation Committee and a National Advisory Group to the subprotocol. These sections encourage the leaders of hospitals, medical centers, and other clinical settings that have residents and fellows in the operative and procedural areas to think differently about how GME provides new opportunities to improve patient safety and health care quality in these complex and critical areas of patient care. Importantly, the findings and discussions encourage CLEs to cultivate future leaders within the surgical and procedural specialties who are committed to systems-based approaches to optimizing patient care.

T he COVID-19 pandemic has created numerous challenges for our communities and their health care environments. As part of the efforts from the Accreditation Council for Graduate Medical Education (ACGME) to understand how COVID-19 is affecting the US graduate medical community, the Clinical Learning Environment Review (CLER) Program is conducting a special assessment of clinical learning environments (CLEs). This CLER initiative will inform the executive and graduate medical education (GME) leadership of clinical sites, the GME community at large, and the ACGME as to how health care organizations that provide GME might use the collective knowledge gained from this pandemic to optimize learning and patient care in both the short and long term. The CLER COVID-19 site visit protocol seeks to provide value to the abovementioned communities through:

he Clinical Learning Environment Review (CLER) Program was developed by the ACGME to provide formative assessment and feedback to the nation’s teaching hospitals and medical centers regarding engaging residents and fellows in patient safety, quality improvement, and other key areas of focus in their patient care environments. 1 The CLER Program’s first National Report of Findings from visits to 297 clinical learning environments (CLEs) was published in 2016. 2 The report highlighted opportunities for graduate medical education (GME) leadership and CLE executive leadership to partner toward the goal of optimizing patient care and the learner experience. In response to that report, the ACGME Board of Directors approved the Pursuing Excellence in Clinical Learning Environments initiative ( Pursuing Excellence ). 3 The Pathway Innovators Collaborative represents a core activity within Pursuing Excellence , and an overview of this Collaborative has been presented in a prior publication. 4 In brief, the overall design of the Collaborative was based on a social learning model similar to that developed by the Institute for Healthcare Improvement’s Breakthrough Series. 5 This model examines change by asking about the goal of the change, the anticipated from the change, and if the change led to that improvement. The Pathway Collaborative included teams from chief executive officer (CEO) and official (DIO). is relevant for CLER visits and Excellence , as this The Collaborative was conducted over a 4-year period with multiple in-person Learning Sessions followed by intersession work. This article provides a detailed perspective on the

Across the United States, inequities in health care persist.Differences in the quality of health care, or health care disparities, occur across numerous dimensions including race, ethnicity, sex, geographic location, socioeconomic status, sexual orientation, gender identity, and many others. 1,2These disparities are complex and likely a result of numerous factors.As a result, meaningful change will require action at all levels of the health care system.For health care organizations, action to eliminate health care disparities includes systems-based approaches to identify and address inherent biases, misguided processes, and missed opportunities to deliver optimal care to all patient populations.Such approaches start with data collection and analysis to inform focused, culturally appropriate quality improvement (QI) initiatives.Engaging new clinicians is a key element of any systems-based approach, as new clinicians will shape the future of health care delivery.Clinical learning environments (CLEs), or the hospitals, medical centers, and ambulatory care clinics where new clinicians train, have an important role in this process.The transition from undergraduate or preprofessional training to clinical care is the optimal time to engage new clinicians as they are just beginning to develop practices that will likely be with them for decades. 3By helping new clinicians continually monitor for equity as they care for patients and by giving them the skills to address disparities in care, CLEs have the potential to change organizational culture and shape a workforce that is prepared to engage with and treat every patient according to their needs.The National Collaborative for Improving the Clinical Learning Environment (NCICLE) developed this document as a guide for CLEs in engaging new clinicians in QI efforts to eliminate health care disparities.As co-chairs of the work group that authored the document, we were privileged to work with an interprofessional team that brought diverse perspectives to the common goal of envisioning a set of expectations for engaging new clinicians in addressing health care disparities.Our hope is that this document will inspire and guide CLE leaders across the country as they develop and implement strategic initiatives to ensure health care equity now and into the future.

PURPOSE The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities. SUMMARY To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Engaging new clinicians is a key element of any systems-based approach, as new clinicians will shape the future of health care delivery. Clinical learning environments, or the hospitals, medical centers, and ambulatory care clinics where new clinicians train, have an important role in this process. Efforts may include training in cultural humility and cultural competency, education about the organization's vulnerable populations, and continuous interprofessional experiential learning through comprehensive, systems-based QI efforts focused on eliminating health care disparities. CONCLUSION By preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities, clinical learning environments are instilling skills and supporting behaviors that clinicians can build throughout their careers-and helping pave the road towards equity throughout the US health care system.

Earlier this year, the Accreditation Council for Graduate Medical Education (ACGME) Pursuing Excellence in Clinical Learning Environments initiative wrapped up an 18-month national learning collaborative focused on engaging residents and fellows in patient safety. The collaborative was the first in the Pursuing Excellence Pathway Leaders collaborative series, which brings together teams from ACGME-accredited sponsoring institutions (SIs) to identify new structures and processes for optimizing the clinical learning environment (CLE) in one or more of the Clinical Learning Environment Review (CLER) Focus Areas. Pursuing Excellence and each of its collaboratives are designed to foster a community where SIs learn from each other and work together to address opportunities identified through the CLER Program’s formative site visit process. By sharing the experiences of the Pursuing Excellence teams in this article and in reports to follow, the CLER Program is promoting ongoing national conversations on how to enhance resident and fellow training in the context of delivering patient care.

The Clinical Learning Environment Review (CLER) Program is designed as a formative evaluative experience for the more than 800 Accreditation Council for Graduate Medical Education (ACGME) institutions that sponsor graduate medical education (GME). The CLER Site Visits assess how the clinical learning environments (CLEs) of these Sponsoring Institutions (SIs) are performing in 6 focus areas of importance to ACGME. The CLER National Report of Findings 20161 included findings from the first cycle of CLER Site Visits, which were conducted at the nearly 300 SIs that sponsor 3 or more core residency programs. The current report presents findings for the second cycle of visits to that same group of CLEs; for each CLE, the second CLER Site Visit took place approximately 24 months after the first. In addition to an update of findings, this report contains a first look at a 2-point analysis and some insights into the types of efforts underway to improve the nation's CLEs.Similar to the first report released in 2016, the CLER National Report of Findings 2018 notes a large degree of variability across the 6 CLER Focus Areas—both within and across CLEs. However, for the first time, it also provides some indications of the directionality of the variation. Variability can be the result of positive forces seeking to bring about change. It can also be a sign of processes that are inefficient or ineffective, thereby representing opportunities for improvement.A noteworthy example of improvement in overall performance is seen in the area of patient safety. The 2018 report notes that many CLEs demonstrated an increase in resident and fellow reporting of patient safety events between the first and second CLER visit. Whereas the degree of overall improvement was modest at the national level, at the individual level, a number of CLEs demonstrated high rates (eg, > 90%) of resident and fellow reporting of patient safety events.Ideally, CLEs who have demonstrated improvements will serve as role models for others by identifying and disseminating the practices that led to their success. When this role modeling happens, the variability both within and between CLEs will likely decrease and the overall national performance will improve. ACGME is seeking to better understand some of these successful practices through the Pursuing Excellence Initiative (PEI).2 Currently, 9 SIs are involved in a PEI collaborative effort to dramatically enhance the degree to which first-year resident and fellow physicians engage with their CLE to address and improve patient safety. It will be important to share the progress of these SIs as they identify successful models for involving residents and fellows in the CLE's infrastructure for addressing patient safety. Over the next few years, ACGME will sponsor PEI learning collaboratives in some of the other Focus Areas as well.One of the biggest lessons learned in the second set of visits to these nearly 300 CLEs has been the positive effect that the CLER Program appears to be having on enhancing the dialog between GME leaders and the executive leaders of the health care systems that serve as CLEs for residency and fellowship programs. While this report's second overarching theme notes that GME continues to be somewhat insulated from CLEs' other areas of strategic planning and focus, feedback from GME leadership indicates that new and more substantial conversations are occurring between GME and CLE leadership. These new conversations indicate a pattern of collaboration that reaches beyond GME's traditional roles of fulfilling the CLE's educational mission and serving as a key component of the CLE's clinical workforce. The new conversations appear to be examining how GME can better align with the CLE's mission to deliver the best patient care and meet the new patient safety and quality performance standards that have emerged in the current health care environment.This report also provides new information that can be used to improve the training experience for resident and fellow physicians. For example, in the area of professionalism, the CLER Program explored several selected topics such as chronic disruptive behavior and managing issues of authorship on scholarly manuscripts. This information is being assessed and reported to stimulate discussions as to whether expectations for professional behavior are consistently practiced within CLEs. Reports from the CLER visits suggest these findings are gaining the attention of health system leadership.The findings of the CLER Site Visits continue to shine an important light on how residents and fellows learn in the context of delivering patient care. The collective findings from the CLER Site Visits indicate that the attributes of high-performing CLEs may be directly associated with the concepts of high-performing learning health systems.34The first set of CLER visits identified that, often, nurses, residents, and fellows work in parallel rather than in an integrated fashion. This was evidenced by the reported lack of collaborative educational or learning experiences and was highlighted as one of the overarching themes in the first CLER National Report.5 This same theme is noted in this second report and is the impetus for evolving one of the CLER Focus Areas (care transitions) to a new area called “teaming” that will be incorporated into future versions of the CLER Site Visit protocol. It is important to note that in this evolution, the CLER Program will not lose the essential elements associated with transitions of care. Rather, these elements will be redistributed and assessed in the context of relevant Focus Areas such as patient safety and supervision.Teaming is one of a number of important attributes of a high-performing learning health system. Over time, it is anticipated that the CLER Program will deepen its exploration of how CLEs invest in, deliberately design, and monitor new models to promote learning and performance within clinical care teams—thereby strengthening the association between the quality of GME experience and the quality of health care in general. The efforts of the National Academy of Medicine and other related work in the areas of learning health systems and high-reliability organizations34 indicate that GME will likely benefit from CLEs who have explicitly focused their organizational efforts on operationalizing and sustaining these concepts.Built on a model of quality improvement, the CLER Program will continue to explore new opportunities to provide the nation's CLEs with information they can use to simultaneously optimize learning and patient care. One mechanism for doing so will be the introduction of subprotocols to enhance the regular site visit process. The first of these subprotocols will focus on the operative and procedural areas, and a second subprotocol will provide insights from the patient perspective. In the future, the CLER Program will also explore the perspective of governance and governing bodies' understanding of the mission and goals of their CLEs—particularly as it affects the quality of GME. The CLER Program will also seek to deepen understanding of the structure and function of medical education across the medical continuum, specifically lifelong learning as seen through continuing professional development.In a final note, the CLER Program would not be possible without the efforts of a large supportive community. The authors of this report thank many members of that community including: the ACGME Board of Directors for its continued interest in the ongoing development of this program; the CLER Program staff—both employed staff and those members of the GME community who have volunteered their time on visits; the members of the CLER Evaluation Committee; other programs within the ACGME who have helped support CLER; and most importantly, all of the individuals within the nation's SIs and CLEs who have helped organize and participate in the CLER visits.

The Clinical Learning Environment Review (CLER) Program assessed and monitored a selected set of observations in each of the 6 CLER Focus Areas1 over the last 2 sets of visits. This section offers the CLER Program's first look at changes over time in each of the Focus Areas. Of note, findings presented in this section of the CLER National Report of Findings 2018 reflect a 2-point analysis; future iterations of this report will present trends. The measures examined are not comprehensive and do not summarize the full scope of resident and fellow engagement in the CLER Focus Areas. Instead, they offer a snapshot that paints a multidimensional picture of the clinical learning environment (CLE). These findings are intended to further stimulate new discussions on continuously improving the CLE. Appendix B provides additional information on selected changes from the first set of CLER Site Visits.The results are based on matched cases (ie, CLEs) and a combination of quantitative (eg, resident and fellow responses to closed-ended questions in group interviews) and qualitative information (eg, observations and interviews on walking rounds). Details on data sources and the methods for analysis are described elsewhere in this report.2The reported changes on selected measures are not designed to imply plausible explanations of effects or to establish causal relationships. Additionally, statistical significance does not necessarily imply practical significance as the differences may not be large enough to have practical implication. Many factors may influence change, such as awareness and understanding of the CLER Focus Areas, opportunities for engagement (eg, participation in patient safety event investigations), and attention to improvements in selected CLER Focus Areas (eg, patient safety and health care quality). These factors may vary across CLEs and change over time; thus, such factors should be considered in interpreting these findings. In the future, the CLER Program will further explore the reasons for such changes.Between-cycle changes on selected measures in patient safety are presented in FIGURE 1. In both sets of visits, a high percentage of residents and fellows reported that the clinical site provided a supportive and nonpunitive environment for reporting errors, with a median (interquartile range [IQR]) finding of 96.7% (93.6%–100%) in Cycle 1 and 100% (96.4%–100%) in Cycle 2.Across CLEs, the percentage of residents and fellows who reported experiencing an adverse event, near miss/close call, or unsafe condition was higher in Cycle 2 than in Cycle 1. In Cycles 1 and 2, the median (IQR) findings were 68.1% (58.0%–76.1%) and 72.7% (63.8%–80.9%), respectively (P < .001). In addition, the percentage of residents and fellows who reported these events into their CLE's patient safety event reporting system increased significantly, with a median (IQR) finding of 46.5% (33.8%–59.9%) in Cycle 1 and 50.0% (37.5%–66.7%) in Cycle 2 (P < .01). Little change was noted from Cycle 1 to Cycle 2 in terms of residents and fellows receiving feedback on the outcome of a patient safety event report submitted into the CLE's central reporting system.Queried separately, the median percentage of residents and fellows who reported a near miss/close call event increased in the second set of visits. In Cycles 1 and 2, the median (IQR) findings were 18.1% (11.5%–26.8%) and 23.3% (15.7%–33.3%), respectively (P < .001). In contrast to these results, the median percentage of residents and fellows who reported participating in an interprofessional patient safety event investigation decreased in the second set of visits, with a median (IQR) finding of 41.2% (31.4%–51.1%) in Cycle 1 and 37.3% (28.6%–50.0%) in Cycle 2 (P < .05).Results related to qualitative information collected on walking rounds and interviews with patient safety and quality leaders are presented in TABLE 1. Across CLEs, the proportion of residents and fellows with a working knowledge of basic patient safety terminology differed between cycles (P < .01). A significantly higher percentage of CLEs in Cycle 2 (76.6%) tracked the number of patient safety event reports submitted by residents and fellows than in Cycle 1 (34.3%, P < .001).FIGURE 2 presents changes on selected measures in health care quality and health care disparities.Compared with Cycle 1, a larger median percentage of residents and fellows (postgraduate year 2 [PGY-2] and above) in Cycle 2 reported awareness of the priorities in quality improvement (QI) at their clinical site—a median percentage change of 3.9% (P < .01). Between-cycle differences were also noted in the proportion of residents and fellows with a working knowledge of QI concepts (TABLE 2); these differences were not statistically significant.A modest increase in the percentage of residents and fellows (PGY-2 and above) who reported that they had participated in a QI project of their own design or 1 designed by their program or department was noted between Cycle 1 and Cycle 2, with median (IQR) findings of 77.4% (66.4%–87.4%) and 79.4% (70.7%–87.9%), respectively (P < .05).Of the residents and fellows who reported that they had participated in a QI project, a significantly smaller percentage in Cycle 2 reported that the project was linked to the clinical site's QI goals (median [IQR], 45.8% [33.3%–64.9%]) compared with those in Cycle 1 (median [IQR], 54.5% [38.4%–69.0%]; P < .01). A slightly higher percentage of residents and fellows, however, reported being engaged in an interprofessional QI project linked to the clinical site's QI goals. In Cycles 1 and 2, the median (IQR) findings were 75.0% (61.5%–87.8%) and 77.4% (66.7%–86.9%), respectively. No statistically significant difference was observed.In the area of health care disparities, a slightly smaller percentage of residents and fellows in the second set of visits reported knowing their clinical site's priorities in addressing health care disparities. In Cycles 1 and 2, the median (IQR) findings were 60.0% (42.4%–74.7%) and 58.7% (42.9%–75.0%), respectively. The difference was not statistically significant. There was also little change in the percentage of CLEs that appeared to have a systematic approach to addressing health care disparities among the at-risk patients receiving care at these clinical sites—less than 5.0% of CLEs in both sets of visits.FIGURE 3 presents between-cycle changes in selected measures related to care transitions. Whereas in Cycle 1, a median (IQR) of 81.8% (71.4%–91.0%) of residents and fellows reported following standardized processes for handling transitions of care from inpatient to outpatient, in Cycle 2, 64.8% (51.0%–78.3%) reported doing so. This change was statistically significant (P < .001).Across CLEs, the percentage of residents and fellows who reported following a standardized process for handling transitions of care during change-of-duty handoffs was higher in Cycle 1 than in Cycle 2, with a median (IQR) finding of 91.7% (83.6%–100%) and 85.7% (77.8%–93.3%), respectively (P < .001). Similarly, of those who reported following a standardized process, a higher percentage in the first set of visits indicated that the process included a standardized written template for communication for handling transitions of care during change-of-duty handoffs, with a median (IQR) finding of 78.9% (70.3%–88.9%) in Cycle 1 and 77.3% (68.4%–86.9%) in Cycle 2 (P < .05).Based on observations during walking rounds, the change-of-duty handoff processes in most CLEs (69.5%) did not appear to be standardized in Cycle 1 (TABLE 3). At the time of the second visit, it appeared there was some standardization in most CLEs (94.8%).Between-cycle changes on selected measures in supervision are presented in FIGURE 4. In Cycle 1, a median (IQR) of 19.6% (10.0%–28.3%) of residents and fellows reported having been placed or witnessing 1 of their peers placed in a situation where they believed there was inadequate supervision. In contrast, a median (IQR) of 25.0% (16.7%–33.3%) of residents and fellows reported the same in Cycle 2 (P < .001).In both sets of visits, a high percentage of residents and fellows reported knowing what they were allowed to do without direct supervision, with a median (IQR) of 100% (95.0%–100%) in Cycle 1 and 96.2% (91.5%–100%) in Cycle 2.Compared with those in Cycle 1, a higher percentage of residents and fellows in Cycle 2 reported having an objective way to know what procedures residents and fellows from other services were allowed to do without direct supervision when they consulted on patients (median [IQR] of 29.1% [16.7%–54.4%] versus 39.1% [22.5%–60.2%], respectively; P < .01).In the majority of CLEs—89.9% in Cycle 1 and 93.7% in Cycle 2—nurses indicated on walking rounds that in the absence of an attending physician, they relied primarily on trust when residents and fellows performed clinical procedures (TABLE 4).Overall, from Cycle 1 to Cycle 2, there was a statistically significant increase in the percentage of residents and fellows who reported that they would power through to handoff if placed in a situation in which they were impaired by fatigue (FIGURE 5), with median (IQR) findings of 30.4% (17.9%–41.3%) and 46.3% (31.3%–58.3%), respectively (P < .001).In addition, the percentage of CLEs where the patient safety and quality leaders recalled 1 or more patient safety events related to resident or fellow fatigue in the past year increased slightly (6.0% in Cycle 1 versus 6.5% in Cycle 2). The change was not statistically significant.FIGURE 6 presents selected measures in professionalism. In the first set of visits, a greater median percentage of residents and fellows reported that their clinical site provided a supportive, nonpunitive environment for coming forward with concerns regarding honesty in reporting compared with those in the second set of visits. Median (IQR) findings were 95.0% (90.4%–100%) for Cycle 1 and 89.7% (83.9%–95.1%) for Cycle 2 (P < .001).In Cycle 1, a median (IQR) of 35.2% (21.7%–48.5%) 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. In Cycle 2, a median (IQR) of 33.3% (18.0%–43.3%) of residents and fellows reported the same. The change was statistically significant (P < .01).The percentage of residents and fellows who reported that they felt pressure to compromise their honesty or integrity to satisfy an authority figure during their training at their CLE was slightly lower in Cycle 2 than in Cycle 1. In Cycles 1 and 2, the median (IQRs) findings were 14.8% (8.6%–20.9%) and 12.5% (6.7%–20.1%), respectively. The difference was not statistically significant.Collectively, the results indicate both progress and challenges across the CLER Focus Areas. The improvements in resident and fellow engagement in patient safety are encouraging, especially those in the recognition of reportable patient safety events and use of the patient safety event reporting system. In addition, the data show that, compared with Cycle 1, a significantly larger percentage of CLEs were tracking the number of patient safety event reports submitted by residents and fellows in Cycle 2. These improvements must be tempered by the relatively small change in the median percentage of residents and fellows receiving feedback on the outcome of patient safety event reports submitted. Additionally, the median percentage of residents and fellows reporting participation in an interprofessional patient safety event investigation has declined since the first cycle of visits.Similar to patient safety, early results indicate progress in health care quality. Challenges continue to exist in addressing health care disparities. Although a larger median percentage of residents and fellows reported knowing the QI priorities at their clinical site and participating in QI projects of their own design or 1 designed by their program or department, the findings also indicate a significant decline in the median percentage of residents and fellows reporting participation in QI projects aligned with the clinical site's QI goals.From Cycle 1 to Cycle 2, little measurable difference was found in the number of CLEs engaged in efforts to routinely monitor and systematically address disparities in health care among their patients. The median percentage of residents and fellows reporting awareness of their clinical site's priorities in addressing health care disparities has also declined slightly.In general, the majority of the measures in care transitions moved in a direction opposite of desired change. Compared with the first set of visits, a significantly smaller median percentage of residents and fellows in the second set of visits reported following a standardized process for handling care transitions from inpatient to outpatient.Across CLEs, fewer residents and fellows reported following a standardized process for handling transitions of care during handoffs between shifts in Cycle 2 than in Cycle 1. Fewer residents and fellows also reported using a standardized written template as part of a standardized process for change-of-duty handoffs. In contrast, it appeared, based on direct observation, that the change-of-duty handoff processes across programs were more standardized at the time of the second set of visits than at the first.A high percentage of residents and fellows across CLEs continued to report knowing what they were allowed to do without direct supervision. At the time of the second set of visits, there was considerable positive change from the first set of visits in the median percentage of residents and fellows reporting that they had an objective way to know what procedures residents and fellows from other services were allowed to do without direct supervision when consulting on patients. However, challenges remain: it appeared that nurses in many CLEs continued to rely primarily on familiarity, trust, or year of training when residents and fellows performed clinical procedures in the absence of an attending physician. In addition, a larger median percentage of residents and fellows reported being placed or witnessing a situation in which they perceived there was inadequate supervision.From Cycle 1 to Cycle 2, there was a marked increase in the median percentage of residents and fellows reporting that they would power through to handoff if impaired by fatigue. CLEs in both cycles had patient safety and quality leaders who recalled patient safety events related to resident and fellow fatigue in the past year.In the area of professionalism, there was a modest improvement in the median percentage of residents and fellows reporting that they had documented a history or physical finding in a patient medical record that they did not personally elicit. From the first to the second set of visits, there was a small decrease in the median percentage of residents and fellows who reported that their clinical site provided a supportive, nonpunitve environment for coming forward with concerns regarding honest in reporting.At the same time, the small decline in the median percentage of residents and fellows reporting that they felt pressured to compromise their honesty or integrity to satisfy an authority figure was promising.The between-cycle findings across the CLER Focus Areas indicate that ongoing formative feedback may be having some effect in advancing CLEs. They also point to opportunities for improvement. In general, the results demonstrate modest progress in some areas (eg, percentage of residents and fellows personally reporting into the patient safety event reporting system), little or no movement in others (eg, percentage of CLEs with systematic and comprehensive efforts to identify and eliminate health care disparities), and undesired movement in other areas (eg, percentage of residents and fellows reporting they would power through when maximally fatigued).Given their dynamic and intricate nature, CLEs can have a considerable time lag between the discovery of challenges, the implementation of systems changes to address these challenges, and the demonstration of results. The selected trends offer a perspective on how CLEs can continue their journey to assess and explore innovative ways to improve the learning environment and to ensure safe and high-quality patient care.

content of the approach.The interactive nature and experience of facilitators were seen as essential for allowing participants to "look at a project from different angles".Key lessons reflect the characteristics of complex systems.Uncovering system interdependencies (interconnectedness) helped learners be "mindful of relationships, constraints and how to manage them".The emergence of unexpected challenges in QIIS exercises (unpredictability) allowed learners to appreciate the importance of experimentation with small-scale QI interventions.Relationship and communication problems between different professional groups in projects (agency) helped learners to reflect on the human and social aspects of QI and build empathy.The benefits of QIIS were reported to go beyond training on technical and social aspects of QI practice.The opportunity to work in groups with colleagues from different backgrounds but experiencing the same challenges allows participants to gather diverse perspectives on problems and share practices, feelings and emotions -"I thought it was only me (…) I feel less alone now".Conclusion: Concepts that sound simple in the classroom can be difficult to apply in practice and require a 'lived experience'.QIIS helps enhance participants' knowledge of the reality of QI in complex healthcare environments in a way that it is applicable to their daily practice.Unlike most QI training, it is focused on experiential case study learning, allowing participants to acquire practical skills of reflection on their actions.The closer the case-study is to problems that learners face in their daily practice, the more this approach is effective, as participants are more engaged.

In 2012, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Clinical Learning Environment Review (CLER) program as a component of its new accreditation system.1 CLER is an assessment program designed to provide formative feedback to the leadership of sponsoring institutions, their clinical sites, and graduate medical education (GME) programs about desirable attributes of a shared learning environment that encompasses patients, residents, faculty, program directors, and other members of the health care team. CLER assessments are formative; the only requirement is that all ACGME-accredited sponsoring institutions participate in a visit every 18 to 24 months.From 2012 through 2015, the CLER program conducted 297 visits and reported the results in the May 2016 supplement of the Journal of Graduate Medical Education (JGME).2 Central to the program is the question of its effectiveness in identifying challenges and opportunities related to its areas of focus, and its ability to affect positive change in these dimensions.The ACGME continually seeks feedback on programmatic impact. A few weeks after each site visit, the designated institutional official (DIO) receives a written report of findings and is encouraged to submit a response. The responses offer the DIO an opportunity to provide feedback on the site visit experience and share plans for how institutional leadership intends to use the findings to improve the clinical learning environment. The ACGME then shares these responses with the CLER Evaluation Committee, which provides oversight and guidance on the program.In the first set of visits, 50% of DIOs submitted a response. While essential, this feedback was voluntary, and it may not have reflected all perspectives within the larger DIO community. To assess the impact of the CLER program, in 2015–2016 the ACGME conducted a national survey of DIOs and published the results in the July 1, 2016, issue of JGME.3We read with interest work by Long et al,4 who report the results of their national survey of DIO perceptions of the CLER program. To our knowledge, their survey is the first national study of the CLER program conducted independently of the ACGME. It is reassuring that on many dimensions the results are consistent with the findings of the prior ACGME survey.3Long and colleagues4 report that nearly two-thirds of executive leaders viewed the CLER experience positively, and nearly one-third of DIOs reported receiving new resources in 1 or more of the CLER focus areas. It appears that these added resources are allocated in the absence of an ACGME requirement. This finding suggests that the GME community is leveraging the CLER program to advance resident education and engagement in improving patient safety, health care quality, and the other areas of focus.Long et al4 also identified opportunities to improve aspects of the CLER program, which is consistent with the CLER team's focus on addressing administrative and other challenges.Of note is the communicated interest in having more advanced notice of the date of the site visit. The CLER program intentionally designed the visits to be short notice, with the intent of minimizing formal preparation and rehearsed responses. The survey by Long et al4 suggests that 44% of sites coached residents and faculty for the visit, versus broadly educating them in the tenets of CLER. Unfortunately, this challenges the CLER program's purpose of promoting unrehearsed conversation and everyday advancement of quality and safety.As the CLER program is preparing for its third wave of site visits, we look forward to using information from the survey by Long and colleagues, along with other input, to assist the ACGME on its journey toward continual improvement of the program's structure.

The Clinical Learning Environment Review (CLER) Program is designed to provide formative feedback to the hospitals, medical centers, and ambulatory care sites that serve as clinical learning environments (CLEs) for ACGME-accredited residency and fellowship programs 1,2 While its main focus is to provide institutions with individual feedback, the aggregate data presented here offer an important overview of the environments where residents and fellows train—and thus can inform the national conversation on optimal attributes for a CLE The collective observations from this first set of CLER site visits portray a community of teaching hospitals, medical centers, and ambulatory care sites that has great capacity to shape the quality of the emerging physician workforce and drive improvements in patient care

For each of the 297 targeted institutions, the CLER teams visited one hospital or medical center that served as a clinical learning environment (CLE) for that SI They spent the majority of their time at inpatient settings, though where possible they also visited affiliated ambulatory care practices in close proximity The hospitals and medical centers varied in size from 41 to 2,396 acute care beds (median=520) The majority (69 4%) were nongovernment, not-for-profit organizations; 21 5% were government, nonfederal; 5 4% were investor-owned, for-profit; and 3 7% were government, federal As for location, approximately 30% of them were in the northeastern US, 29 3% in the south, 25 9% in the Midwest, and 14 1% in the west

The Accreditation Council for Graduate Medical Education (ACGME) has launched a new shared learning collaborative as part of its larger Clinical Learning Environment Review (CLER) initiative. The collaboration, called Pursuing Excellence in Clinical Learning Environments, aims to improve teaching practices and patient care in the hospitals, medical centers, and ambulatory care sites where residents and fellows pursue their formal clinical training in a specialty or subspecialty. The Pursuing Excellence Initiative (PEI) builds on the 2015 report of findings of the CLER program. These findings demonstrate variability across the nation's teaching hospitals in addressing 6 key focus areas. PEI sets up a shared system of collaborative learning among participating sites of ACGME-accredited institutions, in which early participants share advances that will be disseminated through an expanding circle of other participants. The ACGME will award funding to encourage participation in the first major component of PEI. The goal is to stimulate high-leverage changes that will broadly improve patient care and clinical learning environments across the nation.

The ACGME's mission is to improve health care and population health by assessing and advancing the quality of residents and fellows' education through accreditation.1 Over the past few years it has become readily apparent the clinical setting in which residents and fellows learn directly impacts the quality of their training. In order to better understand these environments, the ACGME established the Clinical Learning Environment Review (CLER) Program in 2012.23 The CLER Program is linked to accreditation only in that every institution must periodically complete a visit.The CLER Program focuses on the hospitals, medical centers, and ambulatory care practices where residents and fellows train. Research has shown that young physicians' experience in these institutions shapes the care they deliver for years afterward.45 For that reason, the CLER Program refers to such sites collectively as the clinical learning environment (CLE), a name that underscores their educational significance. In this report, the term CLE means any and all such clinical settings where residents and fellows learn to care for patients. The CLE is much more than a set of places and resources. It also includes the people, their values, and the sense of dedication to team and community.The CLER Program is designed to provide formative feedback that presents graduate medical education (GME) leaders and the executive leadership of the CLE sites with information on six areas of focus: patient safety, health care quality, care transitions, supervision, duty hours/fatigue management and mitigation, and professionalism. Concentrating on these areas helps to ensure that CLEs embrace a culture of continuous improvement and produce physicians who are committed to systems-based improvements in patient safety and health care quality throughout their professional lives.The underlying premise of the CLER Program is that when GME leaders and executive leadership of CLEs are presented with detailed information on how they are addressing the six focus areas, they will use it to build upon their strengths and identify and act on opportunities for improvement—with the ultimate goal of improving patient care while optimizing the educational experience for resident and fellow physician learners.Based on a model that promotes continuous quality improvement, the CLER Program conducts periodic site visits. The site visits are structured to gather evidence that will help answer the five key questions shown above. In the first set of visits, the CLER Program sought to establish a baseline, and—for that reason—focused principally on the first three questions, which address the infrastructure that CLEs have in place for each of the six focus areas and how residents, fellows, and faculty members engage in that infrastructure.The site visits are the core of the CLER Program.23 Essential to the visits are initial and exit interviews that include the GME leadership of the Sponsoring Institution (SI) and the executive leadership of the CLE (e.g., Chief Executive Officer, Chief Medical Officer, and other members of executive management) as well as structured interviews with the CLE's leaders in patient safety and health care quality, residents, fellows, faculty members, and program directors.The CLER team also conducts walking rounds of a number of clinical areas (e.g., clinical inpatient and outpatient areas, perioperative areas, intensive care, emergency departments)—using this opportunity to interact with residents, fellows, faculty members, nurses, and other health care professionals.At the conclusion of the CLER visit, the leaders of GME and executive leaders of the CLE receive an oral report that synthesizes the team's findings in the six focus areas—followed by a written report. The findings in the reports do not influence the accreditation status of the SI or its programs. Rather, the reports provide individual CLEs with observations and information that can be used at their discretion to improve resident and fellow training and promote continuous improvement in the CLE.In parallel with establishing the CLER site visit program, the ACGME also formed a CLER Evaluation Committee for the purpose of providing oversight and guidance. The CLER Evaluation Committee is made up of experts in a broad range of relevant subjects—including those with experience in GME, health care administration, patient safety, health care quality, and other aspects of the six focus areas—as well as resident members and representatives of the public.As the oversight body for CLER, the Evaluation Committee is charged with setting expectations for the six focus areas and providing institutions with national aggregated data from the site visits to help guide improvements in the CLE.The Evaluation Committee began work in the fall of 2012 and helped formulate the protocol used in this first set of visits. Early on, the members of the Committee recognized an opportunity to provide the GME community, teaching hospitals and medical centers, and the public with guidance on optimizing the CLE. The Committee devoted much of its first year to sharing expertise, gathering input from various key stakeholders, and reviewing the qualitative findings from the first 100+ CLER visits. The committee members then developed the CLER Pathways to Excellence6 as a publically available resource with the goal of improving GME training while also improving patient care.78The Pathways document outlines a series of expectations for optimizing the CLE across the six focus areas. For each area, the document defines multiple pathways and numerous properties for each pathway.This report presents findings from the first set of CLER site visits to participating sites of 297 ACGME-accredited SIs of residency and fellowship programs. These visits, conducted from September 2012 through March 2015, focused primarily on teaching hospitals, medical centers, and ambulatory sites that host three or more core residency programs. The CLER Program elected to begin with these larger SIs so as to gather information on the sites that affect the majority of residents and fellows in training. First time visits to the rest of the SI community—approximately 400 ACGME-accredited SIs that have two or fewer core residency programs each—began in September 2015 and will take approximately three years to complete. These visits encompass many rural and safety-net sites for clinical care. The results from visits to the smaller SIs will be published separately later.The findings from the larger SIs are presented in this report from several different perspectives, ranging from broad-based overarching themes to detailed descriptions for each of the six focus areas. The appendices include a number of technical tables and figures.The section on overarching themes9 presents broad, high-level observations that cut across the six CLER focus areas and comments on issues related to infrastructure, alignment of leadership, and strategic use of resources. The section on challenges and opportunities10 highlights three to five key findings within each focus area and provides commentary on their potential impact on GME and patient care. The section on detailed findings11 presents a more comprehensive look at the CLER data in both narrative and graphic form. This section includes the findings highlighted in the section on challenges and opportunities, as well as additional data for each focus area. The report concludes with a section on some of the noteworthy lessons learned12 and a preview of future directions for the ACGME and the CLER Program.

The Accreditation Council for Graduate Medical Education (ACGME) established the Clinical Learning Environment Review (CLER) Program in 2012. The purpose of the CLER Program is to provide the clinical learning environments (CLEs) that serve as the sites for the education of more than 120 000 residents and fellows in ACGME-accredited programs with periodic feedback that addresses 6 focus areas: patient safety, health care quality, care transitions, supervision, duty hours/fatigue management and mitigation, and professionalism.1,2 The aim is to present information to promote discussions and actions to optimize the educational experience of residents and fellows in the CLER focus areas and to improve patient care.3 CLER staff surveyed designated institutional officials (DIOs) from the initial round of CLER visits to assess early perceptions of the CLER Program and its initial effects.CLER site visits are structured to involve interviews with graduate medical education (GME) and CLE executive leadership, the organization's leaders in patient safety and health care quality, residents and fellows, faculty members, and program directors, along with observations and interview data gathered during walking rounds of the site's clinical units.1,2 At the conclusion of the visit, GME and CLE executive leadership receive an oral report of findings in the 6 focus areas, followed by a written report with a detailed set of observations to help target improvement efforts.As part of a systematic effort to improve the CLER Program, an online survey was distributed in September 2015 to DIOs of the 297 ACGME-accredited sponsoring institutions (SIs) with 3 or more ACGME-accredited core programs that had an initial CLER visit (September 2012–March 2015). The purpose was to assess perceptions of the first round of CLER visits and the changes made by each institution to improve its CLE.Requests for participation in a 14-item online survey were sent via e-mail, followed by 3 reminders. The survey included closed and open-ended questions on the value of the written CLER report; institutional engagement in the CLER focus areas; changes made to improve the CLE since the CLER visit and resources needed for this; valuable aspects of the CLER Program; and suggestions for improving the visit process.Analysis of quantitative data included frequency counts, percentage distributions, and 1-way analysis of variance was used to compare and identify differences in means by year of visit, regional location, number of programs at institution, and responding DIOs' years in their role. Statistical analyses were conducted using SPSS Statistics version 22.0 (IBM Corp, Armonk, NY). Analysis of qualitative data involved coding to identify themes using NVivo 10 (QSR International, Melbourne, Australia). The frequency with which each theme occurred is reported as percentages.A total of 231 DIOs responded to the survey (78% overall response rate). Data for 7 respondents were excluded from the analysis due to incomplete responses, and an additional 29 responses were excluded because the respondent was not the DIO at the time of the CLER visit. This yielded 195 usable responses (66% final response rate). Table 1 presents general characteristics of responding DIOs and their SIs. Fifty-six percent of the institutions visited had 18 or more ACGME-accredited programs, and 51% of responding DIOs had been in their position for 6 or more years.Forty-five percent of DIOs (88 of 195) reported their institution's GME community was moderately engaged or very engaged in developing strategies in the CLER focus areas before the first CLER visit; 84% (163 of 195) agreed or strongly agreed that the GME community was more involved in improving 1 or more CLER focus areas as a result of the visit (see table 2 for mean ratings).GME engagement before the initial visit was significantly associated with the year of the first visit. Compared to DIOs who had an initial visit in 2014, those with a visit in 2012 and 2013 were less likely to perceive their GME community was engaged. Among the SI- and DIO-related characteristics assessed, none were significantly associated with GME engagement after the first visit. Eighty-five percent (22 of 26) of DIOs who reported that their GME community was slightly engaged or not at all engaged in developing strategies in the CLER focus areas before the first CLER visit agreed or strongly agreed that their GME community was more involved as a result of the first visit.Overall, 85% (165 of 195) agreed or strongly agreed that the written report provided information that helped their institution target areas for improvement in their CLE.When asked about changes made in the CLE since the initial CLER visit, 8 general themes emerged from 382 lines of coded text, shown in figure 1. Themes included (1) increased focus on patient safety and quality improvement (QI); (2) increased focus on resident supervision and improving mechanisms for assessing resident and fellow competency to perform clinical procedures and dissemination of this information; (3) structural and other changes by clinical sites to address the 6 focus areas, such as the establishment of committees to integrate the focus areas into GME and CLE initiatives; and (4) improving care transitions, most often through standardized approaches. Other themes included changes in GME and CLE executive leadership, duty hours and fatigue management and mitigation strategies, efforts aimed at enhancing professionalism, and efforts to improve data collection and reporting. Within the most prominent theme—enhancing patient care quality and safety—specific initiatives included an increased focus on QI and patient safety at resident orientation and through formal curricula; increased resident and fellow participation in QI and patient safety initiatives; and increased education of residents and fellows in the use of patient safety reporting systems.In relation to resources needed to improve the learning environment, the 3 main themes are shown in the box. Within the theme of professional development, DIOs mentioned the importance of developing faculty competency and expertise in the CLER focus areas, such as techniques to improve patient safety so that effective role modeling and reinforcement can occur. They also commented on the need for protected time to attend faculty development sessions, pursue research, champion innovative teaching, and ways to effectively educate, mentor, and assess resident learning as part of successful educational efforts.The second theme pertained to the need for faculty and support staff in the institutional GME office to engage in efforts to address the CLER focus areas. Ready access to data or information technology support across the institution was the third theme, including systems that linked patient outcome data to institutional patient safety and QI efforts.In response to the question about aspects of the CLER Program that DIOs viewed as valuable, 7 general themes emerged and are shown in figure 2. The benefit of receiving formative feedback to identify areas for improvement related to the CLER focus areas was the leading theme. DIOs also reported that the visit helped increase awareness of the role of the GME enterprise in enhancing quality and safety in the CLE, focused attention on the importance of the CLER focus areas, and increased collaboration and engagement between GME and CLE executive leadership in improving resident and fellow training in the focus areas.When asked about suggestions for improving the CLER site visit process, DIOs expressed the need for more time to prepare for the visits. In addition, they suggested adding comparative data in the written report and more flexibility on who can attend the group meetings.The results of the survey suggest a positive perception of the CLER Program. As a result of the initial CLER visit, DIOs reported that the GME community is more involved in the focus areas, particularly in CLEs where there was little or no engagement prior to the visit.In terms of outcomes, the findings indicate that most improvement efforts are currently concentrated in the areas of patient safety and health care quality, with emphasis on educational activities to increase awareness of initiatives in these areas, as well as improving supervision and care transitions. These changes reflect how CLEs have utilized the information from the site visits to identify and prioritize areas for improvement in the 6 focus areas.Consistent with the aims of CLER, DIOs appeared to recognize the value of formative feedback to improve the CLE. They also acknowledged that the program set expectations for the integration of GME within the CLE to improve both resident and fellow training and patient care. DIOs indicated that an important value of the CLER Program is that it underscores the engagement of both GME and CLE executive leadership—elevating the dialogue on how best to improve resident and fellow engagement in the CLER focus areas.The results also provide insights into areas for improving the CLER Program. Given the current focus on QI and patient safety, the CLER Program will need to identify ways to help drive improvement in the other focus areas. The survey also identified opportunities to improve the site visit experience to enhance engagement between GME and CLE executive leadership, increase interprofessional dialogue, and address operational issues such as scheduling.As with all studies, there are limitations that should be considered. The findings are based on visits to larger SIs with 3 or more core specialty programs and may not generalize to smaller SIs. In addition, institutions with visits during 2012 and 2013 may have had more time to experience change. Finally, although the survey was administered anonymously, a study conducted by investigators external to ACGME may have produced different findings.The DIO community is reporting changes that are related to the formative feedback from the CLER Program and the resulting learning. Over time, the CLER Program will continue to assess how these changes translate into actions that improve the quality of the CLE and the impact of this on resident and fellow education and, ultimately, patient care. The findings highlight challenges that exist to improve the CLE and the ways in which to improve the quality of the CLER visit experience, as well as offer opportunities to maximize learning from the initial implementation of the CLER Program in ongoing program refinement.