CLER Overview

1. CLER Overview Program Coordinator Meeting December 10, 2013

2. What is CLER? • Component of ACGME’s Next Accreditation System. • Focus on educational/working environment, not accreditation requirements. • Goal to provide feedback to DIO and CEO of hospital. • DIO will receive a CLER Site Visit Report. • Every 18 months. • 10-14 days notice. • 2-3 days. • First visit to University of Utah Hospital only. • Results of first visits are baseline and will not be used in making accreditation decisions.

3. 5 Key Questions • Who/what form the hospital’s infrastructure? • How integrated is GME into hospital efforts? • How engaged are the residents? • How does the hospital determine success in integrating GME? • What are the areas the hospital identified for improvement?

5. CLER’s Six Focus Areas • Patient Safety • Do residents report patient safety issues ? (errors, unsafe conditions, near misses) • Do residents participate in inter-professional teams to promote patient safety? • Quality Improvement • Are GME leadership, faculty, and residents integrated into the hospital’s quality improvement activities? • Do residents learn how to identify opportunities for reducing health care disparities? • Do residents use data to improve systems of care?

6. CLER’s Six Focus Areas • Transitions of Care • Is there effective standardization and oversight? • Does the hospital facilitate professional development for residents and faculty about transitions of care? • Supervision • Does the institution establish and monitor policies for effective supervision of residents? • Do all residents have protected mechanisms to report inadequate supervision? Do/would they use them?

7. CLER’s Six Focus Areas • Duty hours, fatigue management & mitigation • Are faculty and residents educated about fatigue? • Is there institutional oversight and monitoring of duty hours across all programs? • Professionalism • Do we educate/monitor behavior of residents & faculty? • Is reporting of program information to the ACGME complete and accurate? • Do residents report their duty hours accurately?

9. Meetings • Senior Leadership • CEO, DIO, Resident from GMEC Required • CMO, CNO highly encouraged • Quality and Patient Safety Officers • Peer Selected Residents • Core Faculty • Program Directors

11. How can you help? • Identify peer-selected residents for resident meetings; not chosen by a chief resident or other program representative. • Broad representation across programs; more from larger programs; PGY-2 or above. • Identify senior/chief residents for “walking rounds” hospital tours. • Different individuals for each of the walking rounds; preferably from different specialties. • Identify “core” faculty for faculty meetings. • Broad representation of residency and fellowship programs. • Suggest rooms that will accommodate up to 30 participants; AV enabled; no auditoriums.

12. Who are Core Faculty? • All physician faculty who have a significant role in the education of residents/fellows and who have documented qualifications to instruct and supervise. • Must devote at least 15 hours per week to resident education and administration. • Should evaluate the competency domains; work closely with and support the program director; assist in developing and implementing evaluation systems; and teach and advise residents.

13. Questions?