Challenges and Opportunities in the 6 Focus Areas: CLER National Report of Findings 2018

The findings in the present report are integral to the nation's understanding of the current condition of how clinical learning environments (CLEs) are engaging residents and fellows in the CLER Focus Areas.1 They also provide insight on how CLEs can continuously take important steps designed to purposely enhance the connection between graduate medical education and optimal patient care. Findings from the second set of CLER Site Visits suggest that CLEs are continuing to raise awareness in the CLER Focus Areas through education and training. There is also evidence that CLEs are working to establish mechanisms to improve patient safety in their organizations. For example:As demonstrated in these examples, the present findings revealed positive attributes of the CLEs visited. As the reader will likely see, these findings also revealed continuing challenges and opportunities for improvement. By disseminating these findings, the CLER Program aims to stimulate conversations necessary to achieve a full understanding of CLEs and implement appropriate action to improve the quality of the learning environment and patient care.This section presents the views of the CLER Evaluation Committee on the significance of the findings from the second set of CLER Site Visits and the challenges and opportunities within each CLER Focus Area. The highlighted text presents selected findings based on both quantitative and qualitative results drawn from the CLER site visits. (Please refer to the Methodology section2 for more information on the specific terminology used in describing the results.) As with the section reporting on the overarching themes,3 the CLER Program staff presented the CLER Evaluation Committee with a summary of results in each of the CLER Focus Areas to review in the development of this section.2 The findings that follow are numbered for easy reference within the report. These numbers do not suggest order or importance.The following sections highlight the need for CLEs to move from awareness and knowledge to comprehensive training and interprofessional engagement that includes experiential learning and demonstrated competence in the CLER Focus Areas. Additionally, other areas may require CLEs to further explore system-wide strategies to enhance the quality of learning and patient care in clinical settings.Improving patient safety has to start with those who are closest to daily direct patient care. In this regard, it is essential that residents, fellows, and faculty members fully participate in their CLE's systems and processes for improving patient safety.The findings from this cycle of CLER visits suggest that graduate medical education (GME)–based curricular efforts, such as presenting information at resident and fellow orientation and offering web-based modules, are insufficient to ensure effective ongoing engagement in systems-based efforts to address patient safety. To enhance participation, CLEs need to involve residents, fellows, and faculty members in purposeful, planned, and continual experiential learning.The findings suggest that residents and fellows have an awareness of their CLE's process for reporting patient safety events. However, overall resident, fellow, and faculty reported use of these systems remains modest.Residents and fellows may not use the CLE's patient safety event reporting system for a variety of reasons, including belief that the chain-of-command is preferred. Resident and fellow behaviors that involve reporting patient safety events through chain-of-command may be embedded norms. In these situations, GME's model of supervisional hierarchy may be unintentionally and counterproductively being applied to patient safety event reporting.CLEs that primarily rely on the chain-of-command for patient safety event reporting may benefit from examining this approach for its impact on patient care and its effect on role modeling. As reports work their way up the chain from junior residents to senior residents to faculty, important information may be filtered out or lost along the way—thereby preventing the CLE from knowing and sharing the full breadth and extent of the events affecting their patients. CLEs that recognize chain-of-command as a mechanism for patient safety event reporting need to monitor the ability of this approach to ensure optimal input.Residents and fellows may also choose not to use the CLE's patient safety event reporting system based on beliefs that reporting is not a physician responsibility and, therefore, can be delegated to other health care team members. This may also be true of faculty members.It is important that executive and GME leadership use active collaborative interventions to increase faculty engagement in reporting patient safety events and emphasize the faculty member's value as role models to residents and fellows. As noted in the CLER National Report of Findings 2016,4 executive leaders have a responsibility to ensure that faculty members have the skills to educate and train residents and fellows to become in and a of of reporting residents, fellows, and faculty members may to of from the CLE that how patient safety event reporting results in patient care. a resident, fellow, or faculty a to or patient safety event report that with specific efforts, it is important for each patient safety event to be both as a learning for the who the to report the as as an to improve patient CLEs will likely need a that includes active efforts in patient care that can be to the patient safety event reporting of the challenges of patient safety is that primarily on events. events are events and at the of system it is important to emphasize the role of reporting and reporting of events or the of to patient safety use efforts to patient safety or patient care. 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interprofessional to be the event is also used for the these as that residents and fellows to participate in comprehensive patient safety event and has the of the this of it is that the CLER visits to in and working knowledge of quality these and other health care that as CLEs have efforts to to and it that this health system knowledge and is not and to residents and fellows their GME noted in the from the National from the CLER site visits suggest that and to is They have the to work through the full of an may an to or implement a with knowledge of the evidence and for training in of is necessary to the skills essential to improving health care CLEs that do not fully residents and fellows in their efforts important opportunities to enhance the quality of patient sections of this report highlight that GME faculty also in their understanding and of and it that CLEs may a of faculty who are in and the of faculty in and care and their as role it is essential for CLEs to in faculty 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executive leadership the and in interprofessional efforts, residents and fellows have the to a comprehensive understanding of how to achieve through interprofessional engagement in positive models that enhance patient and findings highlight residents and fellows their skills primarily in the of and do not the skills of on their patient to and improve patient care. is essential that patient be of the learning process residents and fellows become the health care systems in work will to to and other reported in these will be to their or medical is important for GME leadership to work with executive leadership in both and health information to improve and to and use of of the to be how the system the role of residents and fellows and how can patient care to residents and fellows. the for resident and fellow learning and patient as as sharing with residents and fellows that resident and fellow and and that the interprofessional team are also other important challenges are likely to be and 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