Sunday, April 27, 2014

CLER progress?

The ACGME, the body that certifies US residency training programs, notes:

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

One requirement of the program is supposed to include "opportunities for residents to report errors, unsafe conditions, and near misses, and to participate in inter-professional teams to promote and enhance safe care."

I've been looking for a "cler" presentation of the results of the site visits on this matter, but I can't find anything on the ACGME website or elsewhere.  According to this document, the ACGME has accredited 9516 programs in 2013-14, covering 121,778 full-time residents.  The page that indicates which programs are on probation (unfavorable status), shows the number to be 39, but it does not list the reasons.

Here are my questions. I know from personal visits and discussions with residents that many hospitals do not satisfy the requirement cited above. Have any of these programs been put on probation?  Whether on probation or not, will the names of hospitals that fail this test be made public?

If a patient-safety-oriented medical student applying for the residency match program wanted to know which hospitals do not satisfy this requirement, how could he or she find out?

Finally, I wonder if the CMS payments to hospitals for residency training should be based in some way on the extent to which core requirements and competencies are met, rather than the current fixed number of dollars per student?  (See the past part of this article by David Mayer on this topic.)


Rosemary Gibson said...

Here's an idea. What if there were a "Trip Advisor" rating system whereby residents could give 1-5 star ratings for the safety culture in their sponsoring institution.

Residents have the right to know the safety culture of the training environments they are considering applying to.

Better yet, the ratings would get the attention of the sponsoring institutions' leadership.

An outside-in strategy is the best way to accelerate reform.

Institutions with small numbers of residents may need to be excluded so as to protect the residents.

Am interested in hearing from readers who want to figure out how to make this happen.

Rosemary Gibson

Lou said...

A friend of mine related her recent experience in residency training program safety issues. She felt forced to resign in haste to protect herself from possible litigation and medical staff censure after much prolonged protest over issues of patient safety at the hands of residents that were acting independently without seeking supervision and without sanction from residency program leadership. Things like performing deliveries without notifying the faculty member on call to be present for safety AND billing purposes, performing uterine curettage in the ER on cases of incomplete miscarriage, etc.

She related multiple attempts to bring this situation to light with departmental leadership and medical staff leadership to no avail. When she reached out for help to the national organizations such as ACGME, ACOG – Residency Review Committee, etc., she relates a clearly apathetic response. Not one wanted to be involved. According to her they didn’t even seem interested. According to her she has zero faith in these safety initiatives. In fact, she feels now that she is being held out as the bad guy for making an issue of rogue resident behavior endangering patients yet the problem remains.

Jordan said...


Correct me if I am wrong, but I am not sure that CLER site visits have come into full blown effect as of the 2013 academic year. I know that we are preparing for our first visit this coming year at my program. My understanding is that CLER is suppose to be a "non-punative" approach to facilitating patient safety/QI curriculum across the spectrum of ACGME accredited programs.

When I was applying for residency programs, one program was required to send a letter informing me of their probationary status on interview offer, however, it was difficult to try and find out why they were placed on probation. This information should also be fully disclosed to applying residents.

One problem that I forsee is that CLER site visits could be a way of regulating and punishing programs who have not been given the tools or funding to support resident QI/ patient safety curriculum. I think many programs will checkbox the requirements and prepare for the site visits last minute much like CMS visits.

Rosemary, I hope that one day soon residents will be able to obtain information about programs which have robust QI and safety curriculum for residents. In our regional QI group within the Maryland/VA/DC area we have actually talked about making a list of residency and fellowship programs that we know promote and support these ideals. Creating a public database would be an excellent idea and I'm sure that if we pooled past Telluride alumni we would come up with a ranking list to start with.

Paul Levy said...

Thanks, Jordan. How long will this take? Look at what the ACGME says:

"CLER emphasizes the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care, a key dimension of the 2011 ACGME Common Program Requirements."

It's now three years later. And the program summary on the web page gives no clear dates or deadlines. As Don Berwick has been known to say, "Soon is is not a time."