Detailed Findings From the CLER National Report of Findings 2018

This section includes detailed findings from the second set of visits (2015–2017) of the Clinical Learning Environment Review (CLER) Program. The findings in the 6 CLER Focus Areas1 are based on site visits to the major participating clinical sites (ie, hospitals and medical centers) for 287 Accreditation Council for Graduate Medical Education (ACGME)-accredited Sponsoring Institutions (SIs) with 3 or more core residency programs.23 These clinical sites serve as clinical learning environments (CLEs) for the SIs.Collectively, the 287 SIs oversee 9167 ACGME-accredited residency and fellowship programs, with a median of 20 programs per SI. These larger SIs account for 87.1% of all residents and fellows in ACGME-accredited programs—with a range of 17 to 2156 trainees per SI (median = 246).Approximately 28% of the CLEs were located in the Northeast region of the United States, 30.3% in the South, 26.5% in the Midwest, and 14.6% in the West. The sites ranged in size from 107 to 2654 acute care beds (median = 528). The majority (67.2%) were nongovernment, not-for-profit organizations; 23.3% were government, nonfederal; 5.9% were investor-owned, for-profit; and 3.5% were government, federal. Although the CLER teams spent the majority of their time at inpatient settings, they also sometimes visited affiliated ambulatory care practices in close proximity.In total, the CLER teams interviewed more than 1600 members of executive leadership (including chief executive officers), 9262 residents and fellows, 8164 core faculty members, and 6034 program directors of ACGME-accredited programs in group meetings. Additionally, the CLER teams interviewed the CLEs' leadership in patient safety and health care quality and thousands of residents, fellows, faculty members, nurses, pharmacists, social workers, and other health care professionals while on walking rounds in the clinical areas.As previously described in the CLER National Report of Findings 2016,4 these findings are based on a mixed methods approach to data gathering and analysis to improve the accuracy of the findings by combining quantitative, descriptive, and qualitative evidence in a complementary manner. As such, some of the findings are represented quantitatively while others are described qualitatively.The combination of methodologies and varied representation of findings should be considered when interpreting the results, making comparisons, or drawing conclusions. Both supporting and conflicting evidence may be presented to explain or qualify findings. For example, results from the group interviews may appear more positive than information gathered on walking rounds. Alternatively, practices reported during group interviews may have been verified on walking rounds.During the group interviews with residents and fellows, faculty members, and program directors, an electronic audience response system (ARS; Keypoint Interactive version 2.6.6, Innovision Inc, Commerce Township, MI) was used to collect anonymous responses to closed-ended questions. The results from the ARS were analyzed at both the individual (eg, residents and fellows) and the CLE levels.At the individual level of analysis, results are presented as percentages of the total number of individuals surveyed. For example:At the CLE level of analysis, individual responses were aggregated at the CLE level and results are presented as median and interquartile range (IQR) percentages. For example:Statistically significant differences (ie, P ≤ .05) in responses due to resident and fellow characteristics (eg, residency year) and CLE characteristics (eg, bed size) are also reported. Of note, statistical significance does not always imply practical significance. For example, differences in responses by residency year may be statistically significant but the differences may not be meaningful or large enough to have practical relevance or implications.As described in the Methodology section,5 this report contains a specific set of descriptive terms that summarize quantitative results from both the ARS and specific findings that were quantified from the site visit reports. These terms and their corresponding quantitative ranges are as follows:Besides the quantitative data, this report contains qualitative data from a number of open-ended questions that CLER Site Visitors asked during group interviews and walking rounds. This information, by design, was not intended to be enumerated. For these questions, the site visit teams made an assessment of the relative magnitude of observations at each individual site. To prevent confusion, these results are presented in the report using a set of descriptive terms different from the previously described terms used for quantitative data. The qualitative descriptive terms, which are intended to approximate the quantitative terms above, are as follows:Finally, this section follows approximately the same structure as the individual CLER Site Visit reports received by participating institutions. This structure is intended to facilitate easy comparison between data from an individual site and that of this report, which aggregates results from all 287 SIs. Those who seek additional detail may consult the Appendices (p. 81–124). contains additional information on the sites and contains aggregated quantitative results from the group interviews with residents and fellows, and contains qualitative information from the group interviews and walking CLER of resident and fellow in patient safety with on major of of the patient safety of patient safety and in patient safety and of patient safety members of the executive leadership patient safety as their for patient safety and quality in CLEs that they a of safety that includes residents, fellows, and faculty of the residents and fellows in the group interviews reported that their CLE a and for and other members also reported of the patient safety system to report on individual This on in a or in a that be as this and based on the findings from the site is as to residents, fellows, and other members a and for patient safety CLEs or more for patient safety an or patient safety a system that to be reported to an (eg, a more resident or faculty and a to report to the patient safety (eg, residents and fellows to be of their for patient safety as and walking the CLER Site Visit teams also asked their patient safety all CLEs to be with their system for patient safety of CLEs were to information on the number of patient safety reports by residents and fellows and were to the number of patient safety reports by The CLEs that their system not CLEs the Graduate Medical Education and their with information on the number or of patient safety reports by residents and fellows, was for to report the number or of patient safety reports by faculty members to these same the residents and fellows interviewed on walking rounds to and of the range of patient safety a CLEs of patient safety also varied residents, fellows, and to on patient and other with they not appear to or as patient safety fellows, and to have of the of these and information for system in the and patient of the residents and fellows in the group interviews that they an or while at their This varied by year of and the residents and fellows who reported that they an or that they reported the patient safety using the patient safety varied by year of and the median (IQR) was and varied by CLE bed and of For who not the patient safety the that they on a to the patient safety report, that they on a and that they for the patient and not to a faculty members and program directors in the group interviews were asked residents and fellows when a patient safety of the faculty members and of the program directors that they residents and fellows reported the using the patient safety a of the residents and fellows in the group interviews that they reported a while at the responses varied by year of and this ranged from to with a median (IQR) of responses varied by region and of walking residents and fellows in CLEs that they report patient safety or their of while also with the patient safety system and they or on others to report, was these reports were in the patient safety and fellows the of a report, the time to a report, of and the of as for not The information from the site visits that in of the resident and fellow of patient safety the patient safety system was varied or the group the CLER teams also faculty and program of the patient safety of the faculty members reported that they reported an or in the year (median the program directors, reported that they reported an or in the year clinical at the the median (IQR) was both responses varied by CLE bed size and of the group the CLER teams asked residents and fellows they received on patient safety reports. Of who an or and who a patient safety report or on a or to the report, reported that they received on the of the varied by and year of also and fellows an of the patient safety also for additional information as of a patient safety was for residents to information on the of the to in the system and to improve patient residents, fellows, nurses, and other clinical a to in response to a patient safety CLEs varied in their for and patient safety and fellows also varied in their of these and used the that these were residents and fellows to be of their CLEs the of or to improve care both and at the individual and fellows were in their for and patient safety that walking the CLER teams resident and fellow in the as of patient safety practices (eg, ambulatory and residents, fellows, nurses, and other health care professionals interviewed on walking rounds that residents and fellows not CLEs residents and fellows to have of patient safety and methods (eg, of system analysis, asked to their in patient safety the majority of the faculty members that they were or and in these of the program directors reported as or and the residents and fellows in the group reported that they in a to patient varied by year of and the median (IQR) was with responses by region and of the patient safety and quality that they not resident and fellow in patient safety (eg, number of CLEs the Graduate Medical Education and the with information the number of residents and fellows who in patient safety CLER teams also asked the program directors in the group interviews they resident and fellow in patient safety of the program directors reported resident and fellow (median varied by CLE bed and of the group of the residents and fellows who were year 3 and that they in an of a patient safety that as analysis of system and of an and for varied by the median (IQR) was with responses by CLE bed and of CLER teams also asked faculty members their in patient safety of the faculty members in the group interviews reported that they in an of a patient safety that nurses, and other health care professionals (median the and of patient safety varied both and was for residents and fellows to in to patient safety at and in patient residents and fellows described that the of a patient safety with or or and fellows varied in their of a of a patient safety and and rounds to be the major approach to patient safety members and program directors that and were other to of a patient safety the group of the residents and fellows that they received on medical to reported that was not varied by year of the median (IQR) was with responses by region and CLE bed Of who received that the was and of the residents and fellows in the group interviews that they of CLE to in with a major patient safety that in a patient (median for information on Of with the that they be or in using these CLER resident and fellow in health care quality the of 6 major in and the for health care of the health care quality of health care quality and in quality to quality data, and in CLE to health care of the approach to health care the CLER Site Visit teams the for quality and interviewed both executive and patient safety and quality a number of CLEs to the as of a approach to learning and to improve quality and safety the resident and fellow in for was and fellows as of (eg, number of CLEs resident and fellow at resident and fellow in of these were the resident and fellow in was and for were or The clinical sites also to have structure to residents and fellows to and to in meaningful Additionally, residents and fellows in CLEs were not in the patient safety and quality for health care quality varied some with as for or reported were also on specific as or on to and care the group of the residents and fellows and reported their for health care quality for additional information on asked the same of the faculty members and of the program directors reported the the on and not that with by the executive leadership or the patient safety and quality the with of executive they were to programs with as from the for of the the residents and fellows to have or of and methods as and also number of residents and fellows the approach by their CLE in and to improve patient the approach to residents and fellows health care varied both and between Although some of was as of resident and fellow a number of CLEs to for all residents and in health care to or medical programs, and the and to of the the patient safety and quality that they resident and fellow the group interviews with residents and fellows and reported they in a of their design, or by their program or Of this reported that their was to or more of the 23.3% were Of who reported their were to the reported their Appendices and detailed information on the group interviews and on walking the CLER teams asked residents and fellows to their residents and fellows varied in their of these was for residents and fellows to that with their CLEs described that the of a (ie, also resident and fellow was to and a For residents and fellows, their not and to and was also for residents and fellows to in the interviews on walking a number of and other health care professionals that they were in that residents and the CLER teams faculty members in the group interviews their in reported that they in a with nurses, pharmacists, and other members of the health care (median the group of the program directors reported that their residents and fellows have to for and data for the of health clinical and or quality were reported as of data. and fellows the (eg, in specific reports from these data faculty members that residents and fellows for data was a The and of to residents and fellows varied both and of the residents and fellows in the group interviews reported aggregated or data on their varied by year of and the median (IQR) was with responses by CLE bed and of also the patient safety and quality that residents and fellows data to the care of their with others by their clinical executive were of of health their described to improve to care and or care and for the by residents and fellows from a core (eg, and number of residents and fellows from other and programs reported in these number of executive to health care their or medical than of executive described a specific set of or a approach to and in the care to or the clinical of their patient at for health care approximately of the the executive faculty members, or program directors that some were data or to health care specific patient of these were reported as the group of the residents and fellows reported that they their in in health responses varied by year of and this ranged from to (median varied by CLE bed and of of the faculty members and of the program directors reported that they their with to health care residents, fellows, faculty members, and program directors interviewed in the group interviews were to at for health care at their clinical the group of the residents and fellows reported that they received that was specific to at for health care at their clinical reported that was not specific to the patient reported that was while clinical and that they not received at their a median (IQR) of of the residents and fellows that they received that was specific to at for health care at their clinical site. varied by CLE bed and of also interviews on walking residents and fellows described and in that was and not specific to the care at their clinical site. residents and fellows CLEs in while the group of faculty members reported that they received that was specific to at for health care and care at their clinical site. reported that was and not specific to the patient reported that was and reported that they not received at the of the faculty members in the group interviews reports of their patient to health care (median Of who reported patient data to health care that their residents and fellows the data to in health care (median of the residents and fellows in the group interviews reported that they in a on health care responses varied by year of and also group and on walking residents and fellows that they received CLE data to health care CLER Site Visitors of resident and fellow in care for care in care on care inpatient and and assessment of care for of executive on patient from inpatient to care or at number of executive at of (including resident and fellow as a the executive described to a approach to or more of care they a they using as the (ie, patient and and by for or the (ie, and fellows were in in and their for of residents, fellows, nurses, and other clinical that they in patient safety that the executive not from the to inpatient or from the care to these from and as to and to as as between of fellows, and that during these was to be or to for patient safety of the residents and fellows reported that they in with and other health care professionals on patient responses varied by level of and (median varied by CLE bed and of to in and care between clinical to resident and fellow teams (eg, to inpatient to care was of the residents and fellows in the group interviews that they a for from inpatient to the median (IQR) was with responses by bed and of rounds varied and These of rounds were reported to in the care or for of of the residents and fellows in the group interviews reported that they a for this ranged from to with a median (IQR) of Of the residents and fellows who reported a between reported using a of patient information to facilitate the the median (IQR) was with responses by of and CLE bed size Appendices and information on asked their 23.3% of the residents and fellows in the group interviews reported that this reported that responses per per and than per group of faculty members reported that they resident and fellow to from to in reported that they not in their Of who reported resident and fellow that they by used a assessment used both and a assessment and used of the program directors in the group interviews that their program resident and fellow to from to in reported that their program does not For who that their program resident and fellow that their program by used a assessment used both and a assessment and used the information on walking that the for care at of programs in CLEs also the CLER teams resident and fellow for to programs per the varied both and were in with The varied in the of and other for faculty members were not in these and was and to the of care were also patient safety and quality in CLEs that they patient safety reports for to resident and fellow of they of these care CLER resident and fellow and the this for of and of and patient safety to executive not or specific to resident and fellow their residents, fellows, faculty members, and program directors also reported a of asked to summarize their at their of the residents and fellows in the group interviews reported of the faculty members and program directors also that residents and fellows are the majority of the in the group interviews reported a of close they also reported of the group of the residents and fellows reported that while in at the they been in a or of their in a they was (eg, the was not varied by and level of the median (IQR) was with responses by CLE bed and of asked their in and for of the residents and fellows in the group interviews that they an or who made or when at their the median (IQR) was responses varied by CLE bed and of also of the faculty members and of the program directors that their residents and fellows an or who made or in to that may be patient safety the the of in the on and during of and patient that in these the number of faculty members was for also that clinical the of faculty members to residents and and fellows in when their these as a of patient safety residents and fellows to from or to report or to for due to to appear a of of when to in a of or other when for to of faculty members and program directors to in the and the on resident and fellow for the that to faculty members and program directors medical and of the for of the residents and fellows in the group interviews reported that they they were to varied by level of and a of the residents and fellows in the group interviews that they an to their from other were to when on their This varied by and of the faculty members in the group interviews that they an of which a resident or fellow was to faculty members and program directors reported that this information is in an system and by or individual faculty members and programs directors that and other clinical members (eg, or to the level of when residents and fellows clinical of the the walking that the to this information, varied in their of to this information, or not this information in the of clinical this information to be or CLEs reported in the of an they on or year of when residents and fellows also of the the patient safety and quality patient safety in the year to resident and fellow the group of program directors reported in the they to an of resident or fellow that a patient safety were of patient safety to the and leadership varied in their of patient safety to resident and fellow executive and patient safety and quality that they patient safety as they and of the was for CLEs to for patient safety to the of was as the of the the of and the CLER the of patient safety to that the for and to and the group the CLER teams presented the residents and fellows with a in which a or to a clinical asked the that their report the that was that their presented with the same of the faculty members and of the program directors that was that the resident or fellow report the a of the program directors in the group interviews that when was residents and fellows may be their (median each of the site the residents and fellows in the group interviews were asked to a in which they were the of their this of the residents and fellows reported that they to varied by year of and the median (IQR) was responses varied by of and CLE bed size also this same 26.5% that they a and to be that they resident to their presented with the same of the faculty members and of the program directors in the group interviews the that the resident or fellow to of the faculty members and of the program directors that the resident or fellow or and to be CLER teams also of faculty members and program directors by a in which their is and of their is but for that response to the of the faculty members and of the program directors that the with or clinical the that the for the the time spent on electronic health of patient and with from to for and a of clinical in the of the residents and fellows, of the faculty members, and of the program directors a patient safety to resident or fellow The CLER teams also asked the patient safety and quality a of the the patient safety and quality or more patient safety to resident or fellow program directors were of patient safety to resident or fellow that to be to the patient safety and quality to to patient safety due to resident and fellow was in residents and fellows described of in their that a of and fellows patient patient and as to of the residents and fellows reported some of their faculty members and program directors also of the from others and of or to asked faculty members and program directors the same by the residents and fellows and clinical clinical and and the of and patient CLE to on of for residents and fellows when they were to and on and to and prevent and were they were in response to an to or The and of these varied and to the of these were of a number of The CLER visits on and of each the CLER asked executive or not or in the The executive in of the CLEs that or more been to their a median (IQR) of of the residents and fellows in the group interviews reported that they their CLE a for in This varied by region and of of the residents and fellows in the group interviews reported that while at their they a or in a patient medical that they not (eg, and from varied by level of and group of the faculty members and of the program directors reported that they that a majority of residents and fellows in this the CLER teams asked the faculty members their in the group interviews that they a or in a patient medical that they not the executive leadership in the they to practices using electronic health and other of health the residents and fellows in the group 14.6% reported that while at the they on to their or to an the median (IQR) was with responses by region also of the CLER teams presented the residents and fellows in the group interviews with a in which of their a and the not in the to be as an of the residents and fellows that they the to the with a faculty or their The response was to their to the on the the executive leadership for and of the program directors the that their CLE was or always in reports of the group the CLER teams presented the residents and fellows with a an of a resident that to reported to the chief program and of presented with of they the to that they the or anonymous responses the a with the and they some other of and when asked to that they with the or to or more members of the to seek presented with the same faculty members and program directors in the group interviews also varied in their as to the resident to the residents, fellows, nurses, and other health care professionals described their environments as and in all of the CLEs individuals described the of and as or of the the were described as or in also residents and fellows also described in of and in response to their for residents and fellows to be of the and to by also that they their of The of the response to these varied residents, fellows, and other clinical that they not report of for of