New CLER Insights Into the Operative and Procedural Areas of Clinical Learning Environments

Since its inception, the Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) Program has sought to create a conversation about how the hospitals, health systems, and other clinical care settings that host ACGME-accredited residency and fellowship programs serve as clinical learning environments (CLEs) for our nation's resident and fellow physicians.¹ Over the past 5 years, the CLER national reports have provided the leaders of graduate medical education (GME) and the executive leaders of CLEs with new information aimed at optimizing learning and patient care.^2–4

From the beginning, the CLER Program has experienced challenges in comprehensively including the operative and procedural areas as part of the site visit protocol. The CLER Program recognized the importance of understanding these key clinical areas—both the implications for patient safety and health care quality^5,6 and the implications for how residents and fellows learn in these environments. In its third cycle of visits, the CLER Program implemented a subprotocol in parallel with the regular visit to a sample of 25 of the larger Sponsoring Institutions with ACGME-accredited programs in surgical and anesthesia specialties. The subprotocol specifically addressed the challenges that made it impractical to include the operative and procedural rooms in the regular CLER visit. The main protocol and associated subprotocol explored the 6 focus areas of patient safety, health care quality (including health care disparities), care transitions, supervision, well-being, and professionalism.

The teams for these augmented visits were enhanced with 2 to 4 additional CLER Field Representatives with backgrounds in surgery or anesthesiology. The team members responsible for the subprotocol joined the other members of the CLER site visit team for the initial and exit meetings with executive leadership and the meeting with the leaders in patient safety and quality. Aside from these meetings, they focused exclusively on the operative and procedural areas of the clinical site.

The subprotocol included scheduled meetings with physician and nursing leaders in surgical and procedural areas and meetings with operating room nurses. However, the majority of the subprotocol team members' time was spent on walking rounds observing the preoperative, operative, and postoperative care units, and talking with various members of surgical and procedural teams.

The CLER Program released the first report of findings from the subprotocol in March 2021.⁷ This report provides an important look at these unique CLEs. As with the larger CLER national reports, the key findings of the subprotocol highlight a mixture of strengths and opportunities for improvement—some unique to the perioperative environment and some that are similar to other places within the CLE. Dr Thomas Nasca, President and Chief Executive Officer of the ACGME, notes in his introduction to the report that the findings are important in that they reveal unexpected attributes of the learning environment that may spur new thinking about opportunities to improve the operative and procedural experiences for residents and fellows. The following findings were highlighted as possible opportunities for future conversations:

• enhancing the quality of key components of patient safety, such as the resident role in the time-out at the start of a procedure and the debrief at the end of the procedure;

• enhancing the role of residents and fellows in transitioning patient care in and out of the operative and procedural rooms;

• identifying what information might be important for other members of the interprofessional team to know with regard to the educational goals for the residents and fellows and their expected roles in the case at hand; and

• identifying issues related to equity of care in the operative and procedural areas to better understand how patients with special circumstances, such as language barriers, are supported throughout the perioperative experience.

In addition to these selected findings, the report also includes a rich set of additional findings and related discussions authored by volunteer members of the CLER Evaluation Committee and a National Advisory Group to the subprotocol. These sections encourage the leaders of hospitals, medical centers, and other clinical settings that have residents and fellows in the operative and procedural areas to think differently about how GME provides new opportunities to improve patient safety and health care quality in these complex and critical areas of patient care. Importantly, the findings and discussions encourage CLEs to cultivate future leaders within the surgical and procedural specialties who are committed to systems-based approaches to optimizing patient care.