Preliminary Feedback from ACGME CLER Site Visit August 19-21, 2014 2014 Program Director Retreat Alan J. Smith, PhD, MEd Assistant Dean and Director for GME ACGME Designated Institutional Official (DIO)

Components of the ACGME Next Accreditation System (NAS) Annual Data Collection and Review Milestones 10 year Self-Study Visit prn Site Visits (Program or Institution) Continuous RRC and IRC Oversight and Accreditation Clinical Learning Environment Review CLER Visits

CLER CLER emphasis on responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care. Assessment in six focus areas: Patient Safety; Quality Improvement; Transitions in Care; Supervision; Duty Hours Oversight, Fatigue Management and Mitigation; and Professionalism

CLER The visit addressed the following questions: What organizational structures and administrative and clinical processes does the hospital have in place to support GME learning in each of the six focus areas? What is the role of GME leadership and faculty to support resident and fellow learning in each of the six areas? How comprehensive is the involvement of residents and fellows in using these structures and processes to support their learning in each of the six areas?

We were #203

CLER Visit Structure Visit involved only University Hospital; future visits may involve other clinical sites and affiliated hospitals. Visit began with CLER team meeting with senior leadership group: CEO, DIO, CMO, CNO, GMEC Chair, and resident GMEC member. Additional group meetings with residents and fellows, program faculty, program directors, senior leaders of patient safety and quality management. Series of one-on-one discussions with individual residents and staff (e.g., nursing) on 4 walking tours of various clinical sites within the hospital. Final debriefing/feedback session with senior leadership group.

Impressions from CLER visit CLER team cordial, professional, but tight-lipped. Special attention directed towards CEO during both opening and closing sessions. Emphasis on role of patient safety/quality improvement personnel in integration of resident Q/PS projects. Much discussion on health care disparities & need for hospital plan. Team observed transitions of care in multiple clinical areas; noted need for standardized process.

Oral Report: Quality and Patient Safety Need to increase awareness of hospital’s strategic goals for quality and patient safety among residents, faculty and program directors. Address under-reporting of errors & near misses by residents and faculty; over reliance on nurses to report; provide feedback; implement new system & train in use. Increase understanding of the range of reportable events among residents, faculty and program directors (i.e., what should be reported). Increase understanding of quality & patient safety “terms” among all groups.

Oral Report: Quality and Patient Safety Noted differences among residents, faculty and program directors regarding knowledge of hospital’s quality/patient safety priorities. Standardize time outs for bedside procedures. Link resident Q/PS projects to hospital strategic goals. Increase opportunities for interprofessional Q/PS projects.

Oral Report: Transitions of Care Develop common approach across clinical areas for hand offs (e.g., standard acronym for hand offs). Increase attending monitoring and participation in hand offs.

Oral Report: Supervision Implement supervision process to reduce situations where lack of supervision can lead to patient safety events. Develop objective, accessible system for attending physicians & nurses to know resident competencies for performing procedures.

Oral Report: Duty Hours/Fatigue Management & Mitigation Provide areas where residents can nap/rest when fatigued. Better education and monitoring of fatigue; reduce tendency to “power through” when fatigued. Closer monitoring of moonlighting hour reporting.

Oral Report: Professionalism Reduce incidents of unprofessional behavior among faculty; provide faculty development/education on professionalism. Clarify and educate residents about process for reporting mistreatment/unprofessional behavior. Promote culture of professionalism.

Oral Report: Healthcare Disparities Develop institutional plan for identifying and addressing healthcare disparities. Communicate hospital’s priorities for addressing healthcare disparities to residents, faculty and PDs.

Written Report 6-8 weeks after visit Report will contain raw data (responses) from resident, faculty and program director responses in group sessions (audience response system). Observations from interactions with residents, faculty, nurses & others during walk-arounds. Information from meetings with leadership and QI/Patient Safety staff. Provides reflections and observations rather than recommendations. We will have opportunity to respond (optional).

What the report might look like … (example from Fletcher Allen Healthcare, University of VT)

Next Steps Assess findings and recommendations in the CLER written report. Prioritize and implement improvements and measure outcomes. Incorporate improvements into annual program and institutional reviews/reports. Incorporate CLER Pathways to Excellence.

Sincere thanks to everyone who participated in the CLER site visit!