By Lynne Meyer, PhD, MPH August 2014. What is CLER? CLER Site Visits are required by the ACGME every 18 months (similar style to JCAHO) Focuses on the.

I’m CLER,You’re CLER,

We’re All CLERBy Lynne Meyer, PhD, MPH

August 2014

What is CLER?CLER Site Visits are required by the ACGME

every 18 months (similar style to JCAHO)

Focuses on the learning environment, not just the residency program

Focuses on Patient Safety, Quality, Health Care Disparities, and more

Effective July 2013 for all ACGME-accredited programs

The Big Picture: Resident, Faculty, Program and Institution ReviewsReview of Program Personnel

Review of Program Institutional Review

Every 6 months: Semi-Annual Review of Residents

Once a year: Review of Program by Program Evaluation Committee (PEC)

Every 18 Months: Clinical Learning Environment Review (CLER)

Once a year: Review of Faculty

Once a Year: Review of Program by ACGME Review Committee

PRN: Progress Reports, Focused or Full Site Visits as determined by Review Committee based on data review

Every 10 Years: Self-Study Visit

CLER Site Visit Components: Meetings and Walk AroundsMeet with:

Senior Leadership Quality and Safety LeadershipResidents/FellowsCore FacultyProgram Directors

Walk Arounds to check on 6 focus areas for CLER

Who’s involved?EVERYONE

Program DirectorsFacultyResident/FellowsHospital AdministrationNurses/Technicians/Pharmacists, etc.

CLER Site Visit InformationSHORT NOTICE: 10 days to 3 week noticeVisits will last 2-5 days (probably 2-3 days)Our 1st CLER visit will only be used for

feedback and baseline data

CLER’s 6 Focus AreasPatient SafetyQuality Improvement (including Health

Disparities)Transitions in CareDuty Hours, Fatigue Management &

MitigationSupervisionProfessionalism

CLER Focus AreasIntegration of residents into institution’s Patient Safety programs, and demonstration of impact including opportunities

for residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care

CLER Focus AreasIntegration of residents into institution’s Quality Improvement programs and efforts to reduce Disparities in Health Care Delivery, and demonstration of impact including how sponsoring institutions engage

residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes

Patient Handoffs: A Typical Day on the Wardshttp://

www.youtube.com/watch?v=JzCdoQEYHkY

What processes do you use to standardize and improve your handoffs

CLER Focus Area: Hand-offs

Oversight of Transitions in Care including how

sponsoring institutions demonstrate effective standardization and oversight of transitions of care

We will be implementing a standardized process

CLER Focus AreasOversight of Duty Hours Policy, Fatigue Management and Mitigation including how sponsoring institutions: (i) demonstrate effective and meaningful

oversight of duty hours across all residency programs institution-wide;

(ii) design systems and provide settings that facilitate fatigue management and mitigation; and

(iii) provide effective education of faculty members and residents in sleep, fatigue recognition, and fatigue mitigation.

CLER Focus AreasEstablishment, implementation, and oversight of Supervision policies including how sponsoring institutions maintain and

oversee policies of supervision concordant with ACGME requirements in an environment at both the institutional and program level that assures the absence of retribution

Excerpt from Resident Survey

CLER Focus AreasEducation and monitoring of Professionalism with regard to how sponsoring institutions educate for professionalism, monitor behavior on the part of residents and faculty and respond to issues concerning: (i) accurate reporting of program information; (ii) integrity in fulfilling educational and professional

responsibilities; and (iii) veracity in scholarly pursuits

Excerpt from ADS Annual Update

How would you answer these?What areas have the hospital identified as opportunities for

improvement?What types of patient safety activities are you involved in?What is an RCA?Do you know how your individual QI and patient safety projects

relate to the hospital’s overall plan? Have you reported Medical Errors, Unsafe Conditions, or Near

Misses?What is the process for reporting Medical Errors, Unsafe

Conditions, or Near Misses?How effective is the dialogue during hand-offs? How effective are educational efforts around sleep and recognizing

and preventing fatigue? Is the level of supervision you experience adequate for your level of

training?

SV Components: Walk AroundsPossible Areas of Focus:

Primary focus on hand-off for change of dutyCheck for variability in process and oversight

of resident hand-offsLook for examples of both under and over

supervisionSee if knowledge of need for direct supervision

appears to be limited to GME facultyLook for consistent vs. variable evidence of

effective management strategies for duty hours and fatigue management

SV Components: Walk AroundsWalk arounds of patient floors, OR and clinics: need

experienced chief or senior residents (PGY3 or higher)Random interviews of staff (e.g. nurses, techs,

pharmacist): Talk with nursesTalk with other residents and physicians on unitsPossible patient contactMay ask people encountered about their perspective of

residents related to the six focus topicsThe CLER team will want to observe a handoff without

supervisionMay return in the evening

Accessing the PSR….

https://my.portal.shands.ufl.edu/portal/page/portal/SHCEMPAUTH

After you log in, an express report is available

Examples of Medical ErrorsFailure to employ indicated testsError in the dose or method of using a drugFailure to provide prophylactic treatmentFailure of communicationEquipment failure

Why Report Near MissesNot wait for harm to occurTrigger improvements in weak spots in the

care processAlert others for possible vulnerabilities and

training gapsContribute to planning, recovery testing,

harm mitigation strategies following events that do result in harm

PDQ List

https://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/Lists/PDQ%20List/AllItems.aspx

CLER and our Focus on Patient Safety and QualityWe need to role model and teach these concepts to our fellows, residents and medical students so they become a way of life.

Documentation of CLERWe must document what we teach, what we learn and outcomes for:Patient SafetyQuality Improvement -- if on QI/PS project – document in New

InnovationsTransitions in Care – used a standardized process such as SBAR

or I-PASSDuty Hours, Fatigue Management & MitigationSupervisionProfessionalism

Do you use the PSR when indicated? Do you review the goals and objectives with your learners? Do you provide your learners with feedback? (formative) Do you return your evaluations on time with meaningful

data/comments? (summative)

ResourcesGME Housestaff: Housestaff Patient Safety and Quality Improvement Committee – Lee Titsworth, MD, Chair

http://gme.med.ufl.edu/policy-procedures/patient-safety/https://ufhealth.org/quality-and-patient-safety/welcome

UF Health:  Sebastian Ferrero Office of Clinical Quality and Patient Safetyhttps://intranet.ahc.ufl.edu/ForwardTogether/qualitycenter/SitePages/Home.aspx

ResourcesACGME’s CLER Program http://acgme.org/acgmeweb/

Sites with Curriculum and Cases to work through

AHRQ Patient Safety Network http://psnet.ahrq.gov/

AHRQ webM&M http://www.webmm.ahrq.gov/

VA National Center for Patient Safety http://www.patientsafety.va.gov/professionals/training/curriculum.asp

[email protected] 352-594-6226