Just 10 "CLEQS" Yields Formative Evaluation of the Clinical Learning Environment.

Abstract

Purpose: “Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative” is the lead statement to a 2019 collection of papers exploring research and efforts to improve learning in the context of patient care. 1 The Accreditation Council on Graduate Medical Education’s (ACGME) Clinical Learning Environment Review (CLER) affirms this foundational role by regularly providing clinical settings affiliated with ACGME-accredited sponsoring institutions with periodic feedback to optimize a shared goal—learning to provide safe, high-quality patient care. 2 However, there are currently no tools available to evaluate the CLE that are: (1) appropriate for all health care team members; (2) informed by contemporary learning environment frameworks; and (3) are quick to complete. 3 Our purpose was to create a reliable, evidence-based, short (10 items, < 5 minutes to complete) CLE tool (Clinical Learning Environment Quick Survey [CLEQS]) appropriate for all participants in the clinical workplace (e.g., trainees, clinicians, clinical staff) to monitor the quality of CLEs. Approach: Survey content (items) was developed for each of the 4 construct domains outlined in Gruppen et al’s learning environment construct framework: individual, social, organizational, and material. 4,5 Consistent with CLER 2.0’s emphasis on the health care systems responsibility for the clinical learning environment (CLE), we wanted the items in each construct to align with: (1) existing surveys/data in use in our sponsoring institution (e.g., patient safety, employee engagement); (2) existing education-oriented surveys (e.g., ACGME); and (3) the literature. To be a short/quick tool, 2–3 items per construct (10 items total) were identified, reviewed, edited, piloted using read/think aloud, and then revised by multiple stakeholders to ensure applicability to all health care team members and an expert in research on learning environments. 3 The survey tool tracked time to complete the survey—addressing the feasibility of quick (< 5 minutes) response time. Outcomes: Two hundred and one CLEQSs were completed in 2019 by interprofessional team members in Cardiology, Family Medicine, Internal Medicine, OB/GYN, Radiology, GME leaders who were engaged in quality improvement initiatives in 2 hospitals or affiliated clinics (est. response rate = 70%). Respondents by role/profession: 28% residents/fellows (N = 77/201), 22% faculty members (N = 45/201); and 21% were other clinicians (N = 42/201), such as nurses, nurse midwives, speech pathologists, social workers, and lab techs. The remainders were students and other clinic/lab staff. Respondents typically completed the survey in 1.5 minutes with good reliability (Cronbach’s α = > 0.83). The Cronbach alpha for each of the 4 CLE domains with the overall item ranged from 0.79 for social to 0.50 for personal. CLEQS scores varied by GME teams with GME leaders confirming that their respective team’s results were consistent with service line/unit/program data from other system-wide and accreditation surveys (safety, engagement, ACGME). Team leaders reported that survey data allowed them to focus on celebrating strengths and targeting improvement strategies specific to their teams with the ability to easily readminister the tool. Discussion: CLEQS is a short, reliable, evidence-based survey tool that can be completed by all participants in the clinical workplace to monitor its quality as a CLE. It can be used to monitor progress on team projects that occur in the CLE and/or to achieve standards associated with system-wide and/or GME accreditation tools that are administered annually. Significance: The evidence is clear that the quality of the CLE predicts quality of trainees’ care long after graduation and well-being. 1 All individuals contribute to the CLE’s quality and its learning climate. Having a quick, reliable perception tool aligned with 4-frame learning environment construct 4,5 and existing annual education and clinical data can provide process data to monitor quality of the CLE and guide improvement. Acknowledgments: The authors would like to thank (1) each of the 6 Aurora Health Care GME interprofessional team leaders and members for participating in the pilot as part of their Alliance of Independent Academic Medical Centers’ National Initiative VII (NI-VII) projects on Teaming for Interprofessional Collaborative Practice, and (2) Kayla Heslin, MPH, Aurora University of Wisconsin Medical Group (AUWMG)-Aurora Health Care for her statistical support.