CLINICAL LEARNING ENVIRONMENT REVIEW (CLER)
Duke Graduate Medical Education
Prepared by: Catherine M. Kuhn MD & Alisa Nagler JD, EdD
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KEY POINTS
CLER is a component of the ACGME Next Accreditation System (NAS)
CLER is intended to provide feedback to the institution and encourage resident/fellow
engagement in providing safe, high quality patient care
The CLER Pathways to Excellence document* notes the 6 pathways & 89 properties of
an ideal institution that can be achieved through joint efforts of trainees, GME
leaders, health system executives, and hospital leaders
CLER emphasizes the importance of inter-professional teams in addressing the six
focus areas
“CLER visit is built on model of continuous quality improvement. Its purpose is to evaluate,
encourage, and promote improvements to the clinical learning environment.” *
Six CLER Focus Areas:
Resident
Meeting
Core Faculty
Meeting
Program Director
Meeting
Initial Meeting
Exit Meeting
w/DIO, CEO,
CMO, CSO, GMEC
Chair
w/DIO, CEO, CMO,
CSO, GMEC Chair
Foundational
Learning
Walk
Around
Walk
Around
Exploration & Inquiry
Walk
Around
1.
2.
3.
4.
5.
Patient Safety
Quality Improvement
Transitions of Care
Resident Supervision
Duty hour oversight &
Fatigue Management
6. Professionalism
Review, Clarify &
Feedback
CLER SITE VISIT FLOW
What is your program doing to
teach and evaluate each of these
6 areas?
PRACTICAL TIPS
 Review the CLER Pathways to Excellence (Executive Summary) document
 Recognize how your program teaches and assesses resident performance in the six CLER
focus areas. ASK your GME Program Director if you don’t know!
 Be ready and available to participate in a CLER visit
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IN GENERAL - WHAT TO EXPECT FROM A CLER VISIT
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The institution receives approximately two weeks notice before a CLER visit
ACGME CLER field representatives (2-3 individuals) will visit the institution for approximately 2 days
CLER team meets with executive leaders including Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer,
leaders in patient safety, informatics, GME leaders, program directors, core faculty and residents/fellows
CLER teams visit patient floors and service areas gathering input from staff and patients on the learning and patient care
environment, with resident/fellow ambassadors accompanying them
The CLER team interviews groups of Program Directors, Core Faculty and Residents/fellows separately and uses an
Audience Response System to gather responses from participants
At the end of the visit, CLER team meets with the institution’s executive leaders to share its observations. A written
report follows in 6-8 weeks.
WHAT YOU SHOULD DO BEFORE AND DURING A CLER VISIT
Hospital
Leaders
IN PREPARATION
 Review CLER Pathways
document
 Assist in distributing
information and
details related to CLER
visit
 Identify health system
priorities regarding
disparities in care
 Support chairs/PTDs
with clinical schedule
adjustments as
needed
DURING
 Be available for CLER
team meetings
 Share information
about how the health
system provides safe,
high-quality care with
trainee involvement
Core
Faculty
Residents &
Fellows
IN PREPARATION
 Review CLER Pathways
document
 Identify how your
program is
teaching/assessing 6
focus areas above
 Consider what the
institution provides
regarding the 6 areas
 Understand what
being a core faculty
member means
IN PREPARATION
 Review CLER Pathways
document
 Consider how your
program is teaching &
assessing the 6 focus
areas above
 Know whether you
have been peerselected to meet with
the site visitors
Program
Directors
IN PREPARATION
 Educate core faculty
and residents/faculty
on purpose and
process for CLER
 Consider how your
program is
teaching/assessing 6
focus areas and share
with residents and
faculty
 Review CLER Pathways
document
DURING
 Advertise QI initiatives
(e.g. display posters)
 Support core faculty
and residents to meet
with the CLER team
 Be available for PTD
meetings
DURING
 Be available for CLER
team meetings
 Be prepared to share
stories about
supervision and
training of residents
 Share examples of
teamwork and patient
safety
DURING
 Be available for CLER
team meetings
 Be prepared to share
stories of how you
work in teams
 Be prepared to share
stories of patient
safety and quality
activities
RESOURCES
 ACGME - CLER Pathways to Excellence
http://www.acgme.org/acgmeweb/Portals/0/PDFs/CLER/CLER_Brochure.pdf
 ACGME – CLER Website
http://www.acgme.org/acgmeweb/tabid/83/'/acgmeweb/tabid/436/ProgramandInstitutionalAccreditation/NextAccreditationSystem/ClinicalLearningEnvironmentReviewProgram.aspx
 Weiss, KB, et al. "Advances in the ACGME Clinical Learning Environment Review (CLER) Program." Journal of graduate medical education 5.4 (2013):
718-721.
 Weiss, KB, Wagner, R and Nasca T. "Development, testing, and implementation of the ACGME Clinical Learning Environment Review (CLER)
program." Journal of graduate medical education 4.3 (2012): 396-398.