Clinical Learning Environment Review Research Articles

Teaming in Graduate Medical Education: Ward Rounds and Beyond.

Teamwork in graduate medical education (GME) is often hindered in clinical learning environments where discontinuity among residents, supervisors, and other health care professionals is typical. Teaming is a conceptual approach to teamwork in dynamic environments with constantly changing team members and goals. Teaming is built on principles of project management and team leadership, which together provide an attractive strategy for addressing teamwork challenges in GME. Indeed, teaming is now a requirement of the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review program. However, many clinician-educators and leaders may be unfamiliar with teaming and how to integrate it into their GME programs. In this article, the teaming framework is described with a specific example of how it can be applied to improve hospital ward rounds, a common setting of teamwork breakdown. The goal of this article is to educate and encourage GME leaders as they learn new ways to implement teaming to improve patient care and education in their programs.

The Clinical Learning Environment: Past, Present, and Future.

In this issue of AJMQ, Graduate Medical Education leaders from a large nationally renowned academic medical center describe in detail the "Residents and Fellows Leading Interprofessional Continuous Improvement Teams" program with a focus on the collaboration within their health system in alignment with Clinical Learning Environment review since its inception. In addition, the authors share key outcomes of the program using the reach, effectiveness, adoption, implementation, maintenance framework, additional structural (eg, timeline) and outcome (eg, scholarship) measures for further context within Graduate Medical Education and Undergraduate Medical Education, and describe elements which supported the program's success and lessons learned.

Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study

Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service. A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. Ten American College of Surgeons-verified Level 1 adult trauma centers. All general surgery residents and trauma/acute/surgical critical care fellows were surveyed. The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions. Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Graduate Medical Education in the Military Health System: Strategic Analysis and Options.

At the request of then-Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, Defense Health Horizons (DHH) examined options for shaping Graduate Medical Education (GME) in the Military Health System (MHS) in order to achieve the goals of a medically ready force and a ready medical force. The DHH interviewed service GME directors, key designated institutional officials, and subject-matter experts on GME in the military and civilian health care systems. This report proposes numerous short- and long-term courses of action in three areas:1. Balancing the allocation of GME resources to suit the needs of active duty and garrisoned troops. We recommend developing a clear, tri-service mission and vision for GME in the MHS and expanding collaborations with outside institutions in order to prepare an optimal mix of physicians and ensure that trainees meet requirements for clinical experience.2. Improving the recruitment and tracking of GME students, as well as the management of accessions. We recommend several measures to improve the quality of incoming students, to track the performance of students and medical schools, and to foster a tri-service approach to accessions.3. Aligning MHS with the tenets of the Clinical Learning Environment Review to advance a culture of safety and to help the MHS become a high reliability organization (HRO). We recommend several actions to strengthen patient care and residency training and to develop a systematic approach to MHS management and leadership. Graduate Medical Education (GME) is vital to produce the future physician workforce and medical leadership of the MHS. It also provides the MHS with clinically skilled manpower. Graduate Medical Education (GME) research sows the seeds for future discoveries to improve combat casualty care and other priority objectives of the MHS. Although readiness is the MHS's top mission, GME is also vital to meeting the other three components of the quadruple aim (better health, better care, and lower costs). Properly managed and adequately resourced GME can accelerate the transformation of the MHS into an HRO. Based on our analysis, DHH believes that there are numerous opportunities for MHS leadership to strengthen GME so it is more integrated, jointly coordinated, efficient, and productive. All physicians emerging from military GME should understand and embrace team-based practice, patient safety, and a systems-oriented focus. This will ensure that those we prepare to be the military physicians of the future are prepared to meet the needs of the line, to protect the health and safety of deployed warfighters, and to provide expert and compassionate care to garrisoned service members, families, and military retirees.

Experiential Learning in Patient Safety: A Multi-Center Study Examining Emergency Medicine Residents' Situational Awareness of Hazards via Simulation.

Introduction The 2016 Clinical Learning Environment Review established that experiential patient safety curricula for residents are uncommon. Moreover, these curricula do not incorporate non-technical skills linked to safety, such as situational awareness (SA). We developed an in-situ patient safety simulation exercise incorporating core SA concepts and subsequently assessed exercise feasibility and acceptability, and measured residents' safety SA. Methods A simulation scenario and mock chart were designed, incorporating 16 patient safety hazards. Residents at two institutions reviewed the chart and had 10 minutes in an emergency department room with the simulated scenario to document identified hazards, followed by a facilitated debriefing. Pre- and post-exercise surveys were completed. We used regression analyses to compare exercise performance and survey responses by training year, and measures of proportional difference and association for survey responses. Results This study included 76 of 104 eligible residents (73.1%). Around 56.5% initially reported being comfortable identifying hazards. During the exercise, hazards requiring higher SA were identified less frequently. Senior residents identified more hazards (OR 2.26; 95%CI 1.56-3.28) (mean 8.28, SD1.45); 93.4% expressed satisfaction with the session, and residents reporting comfort increased significantly (89.5%, p<0.001). Conclusion In-situ simulation incorporating SA concepts feasibly provides experiential safety education and enhances resident comfort with safety issues. Visible hazards were often identified; those requiring information synthesis were usually missed, suggesting a need for developing more robust resident SA. While interns demonstrated the poorest performance, senior residents only identified 50% of errors, indicating that patient safety education enhancing SA should begin early and continue longitudinally.

Checklist for Applying for a New Program or Accreditation of an Existing Program

During the past seven years, the education staff, faculty, and hospital administration at Mount Sinai Medical Center in Miami Beach, Florida, have started five new residencies, launched two new fellowship programs, and expanded two existing residency programs. All are Accreditation Council for Graduate Medical Education (ACGME) accredited. We have had three accreditation site visits and one ACGME Clinical Learning Environment Review (CLER) visit in the past two years. The application and accreditation process are complex and require significant work to be successful. This is a step-wise process and one with many people involved. Using a checklist helps us be efficient and successful. I hope this checklist helps others with their application and accreditation visits.

Analysis of the Interprofessional Clinical Learning Environment for Quality Improvement and Patient Safety From Perspectives of Interprofessional Teams.

In 2018 the Clinical Learning Environment Review (CLER) Program reported that quality improvement and patient safety (QIPS) programs in graduate medical education (GME) were largely unsuccessful in their efforts to transfer QI knowledge and substantive interprofessional QIPS experiences to residents, and CLER 2.0 called for improvement. However, little is known about how to improve the interprofessional clinical learning environment (IP-CLE) for QIPS in GME. To determine the current state of the IP-CLE for QIPS at our institution with a focus on factors affecting the IP-CLE and resident integration into interprofessional QIPS teams. We interviewed an interprofessional group of residents, faculty, and staff of key units engaged in IP QIPS activities. We performed thematic analysis through general inductive approach using template analysis methods on transcripts. Twenty individuals from 6 units participated. Participants defined learning on interprofessional QIPS teams as learning from and about each other's roles through collaboration for improvement, which occurs naturally when patients are the focus, or experiential teamwork within QIPS projects. Resident integration into these teams had various benefits (learning about other professions, effective project dissemination), barriers (difficult rotations or program structure, inappropriate assumptions), and facilitators (institutional support structures, promotion of QIPS culture, patient adverse events). There were various benefits (strengthened relationships, lowered bar for further collaboration), barriers (limited time, poor communication), and facilitators (structured meetings, educational culture) to a positive IP-CLE for QIPS. Cultural factors prominently affected the IP-CLE and patient unforeseen events were valuable triggers for IP QIPS learning opportunities.

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

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.

Preliminary Evidence Supporting a Novel 10-Item Clinical Learning Environment Quick Survey (CLEQS).

The clinical learning environment (CLE) is a priority focus in medical education. The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review's (CLER) recent addition of teaming and health care systems obligates educators to monitor these areas. Tools to evaluate the CLE would ideally be: (1) appropriate for all health care team members on a specific unit/project; (2) informed by contemporary learning environment frameworks; and (3) feasible/quick to complete. No existing CLE evaluation tool meets these criteria. This report describes the creation and preliminary validity evidence for a Clinical Learning Environment Quick Survey (CLEQS). Survey items were identified from the literature and other data sources, sorted into 1 of 4 learning environment domains (personal, social, organizational, material) and reviewed by multiple stakeholders and experts. Leaders from 6 interprofessional graduate medical education quality improvement/patient safety teams distributed this voluntary survey to their clinical team members (November 2019-mid-January 2021) using electronic or paper formats. Validity evidence for this instrument was based on the content, response process, internal structure, reliability, relations to other variables, and consequences. Two hundred one CLEQS responses were obtained, taking 1.5 minutes on average to complete with good reliability (Cronbach's α ≥ 0.83). The Cronbach alpha for each CE domain with the overall item ranged from 0.50 for personal to 0.79 for social. There were strong associations with other measures and clarity about improvement targets. CLEQS meets the 3 criteria for evaluating CLEs. Reliability data supports its internal consistency, and initial validity evidence is promising.

Pursuing Excellence: Integrating Clinical Learning Environment Staff and Learners Into the Pursuit of Quality, Safety, Equity, and Value

<i>Pursuing Excellence</i>: Integrating Clinical Learning Environment Staff and Learners Into the Pursuit of Quality, Safety, Equity, and Value

Call for Collaboration: The Role of Accreditation in the Transformation, Accountability, and Sustainability of Education in Social Determinants of Health.

Call for Collaboration: The Role of Accreditation in the Transformation, Accountability, and Sustainability of Education in Social Determinants of Health.

Using a Direct Observation Tool (TOC-CEX) to Standardize Transitions of Care by Residents at a Community Hospital.

Background: High-quality transitions of care are crucial for patient safety in hospitals, yet few undergraduate curricula include transition-of-care training. In 2012, the Wayne State University Office of Graduate Medical Education (WSUGME) required its residency programs to use the SAIF-IR mnemonic (summary, active issues, if-then contingency planning, follow-up activities, interactive questioning, readback) to ensure accurate and uniform handoffs. Subsequent program evaluations indicated that resident awareness and adoption of the mnemonic at our primary clinical site, Ascension Providence Rochester Hospital (APRH), could be improved. According to our institution's 2016 Clinical Learning Environment Review (CLER), 88% of residents reported following a standardized transition of care handoff, and 53% reported that faculty rarely supervised their handoffs. A 2016 WSUGME internal survey also revealed low rates of awareness (7% to 10%) of the mandated mnemonic. WSUGME then created a direct observation tool, the Transitions of Care-Clinical Evaluation Exercise (TOC-CEX), for faculty to monitor resident skill in using the mnemonic and thus standardize transitions of care as a practice habit at APRH.Methods: Since 2014, WSUGME had relied on 2 methods for training residents in the required handoff mnemonic: (1) introduction to the SAIF-IR mnemonic during the WSUGME orientation for all interns and (2) simulations during an objective simulated handoff evaluation activity for all postgraduate year (PGY) 1s and PGY 2s. In 2017, WSUGME innovated a direct observation tool, the TOC-CEX, for adoption by faculty at APRH to assess resident knowledge of and monitor their skill in using the SAIF-IR mnemonic in 3 primary care programs. The total number of possible participants was 138, and the actual number of individuals in the sample was 95. A majority (86%) of the observations during the study period were of PGY 1 residents, and thus the analysis reflects the ratings of 99% of all interns but only 69% of all possible residents.Results: WSUGME found that faculty use of a direct observation instrument in the clinical learning environment during 2017-2019 increased awareness and adoption of the SAIF-IR mnemonic among residents. Using a z-test of equal proportions on resident responses on an internal WSUGME survey, we found a significant rise in the percentage reporting yes to the question “Does your program have a mechanism for monitoring handoffs?” (χ2[3]=23.6, P<0.0001) and in the percentage identifying SAIF-IR in response to the question “Does your program endorse a specific mnemonic for organizing the contents of a verbal handoff?” (χ2[3]=45.0, P<0.0001). The increase from 2016 to 2017 is the result of the implementation of the TOC-CEX in the interim (question 1: χ2[1]=12.4, P<0.0005; question 2: χ2[1]=10.1, P<0.0025).Conclusion: Our research found that use of the TOC-CEX to monitor resident handoffs resulted in improved awareness and adoption of the SAIF-IR mnemonic in the clinical learning environment. Program leadership reported that the practice was both feasible and well accepted by residents, faculty, and the APRH chief medical officer as the TOC-CEX became a customary component of APRH organizational culture and was perceived as central to quality patient care.

85. A CLER PATH TO ONBOARDING TRAINING: A NOVEL APPROACH TO PREPARE PEDIATRIC FELLOWS TO WORK AT A CHILDREN'S HOSPITAL

Background Fellows need to be prepared for their clinical tasks to ensure safe and effective patient care. Many fellows graduate from residency and receive limited orientation for clinical learning at a new hospital. Using the ACGME's Clinical Learning Environment Review (CLER) program as a framework for instructional strategies can be an effective approach to prepare fellows for clinical work. Objective: To develop and evaluate a new interactive hospital onboarding program for pediatric fellows and to explore benefits to clinical practice 8 months after training. Design/Methods We implemented a novel Fellow Readiness Conference in alignment with CLER Pathways of Excellence to ensure fellows were well-prepared in domains of care transitions, patient safety, and physician wellness. A needs assessment evaluated the hospital's key elements of patient care for fellows, along with a review of 2018 CLER site visit data. Participants were 1st year fellows (n=64) who attended a didactic session. A post-session and 8-month follow-up survey were distributed. The Kirkpatrick Model was applied using descriptive statistics to assess Kirkpatrick Levels 1 (reaction) and 3(behavior) via means, frequencies, and histograms. Results Data from the 2 surveys are shown in Tables 1 and 2. All fellows completed the post-session survey, rating overall conference impressions as favorable (mean=3.6, SD=0.83) on a 5-point scale; 91% responded that it met or exceeded their expectations (exceeded, 41%). At 8-month follow-up 96% (26/27) of respondents indicated at least moderate confidence in applying skills learned in telephone consult communication;85% (23/27) evaluated the session as effective in helping them to apply safety practices in practice. Conclusion(s) The CLER Pathways are a valuable resource for developing a new orientation program. Our data showed benefits in several training areas, and a need to place a stronger emphasis on adverse event education. Escalation of care was added to the 2019 conference. Based on this program's success, we plan to expand the conference to add additional CLER pathways.

Assessment of Training in Health Disparities in US Internal Medicine Residency Programs

Health disparities continue to exist despite the call to increase education of health care practitioners. An assessment of health disparities education has not been previously studied in a national cohort. To describe and compare the curriculum on health disparities from the perspective of program directors and perceptions of training among internal medicine residents. This cross-sectional survey study used a survey of US internal medicine program directors, the 2015 Association of Program Directors in Internal Medicine annual survey, which included questions about health disparities curriculum, and a 1-time survey of US internal medicine residents that asked questions related to their training in health disparities on the American College of Physicians 2015 Internal Medicine In-Training Examination. All internal medicine program directors who were members of Association of Program Directors in Internal Medicine (368 of 396 accredited programs), and internal medicine residents who took the Internal Medicine In-Training Examination were eligible. Final analysis of the merged data set was completed in 2018. Questions were included on the annual Association of Program Directors in Internal Medicine survey and the Internal Medicine In-Training Examination. Program directors reported on presence of health disparities curriculum, educational methods, quality, barriers and challenges to curriculum, and Clinical Learning Environment Review. Residents reported whether they received training and quality of the training in health disparities. A total of 227 program directors (response rate, 61.7%) and 22 723 residents (response rate, 87.2%) responded to the surveys. A total of 90 program directors (39.6%) reported a curriculum in health disparities, but among these, only 16 program directors (17.8%) felt quality of their education was very good or excellent. In more than half of the programs (52 programs [55.9%]), outcomes of the curriculum were not measured. After merging, the combined data set included 18 883 residents from 366 APDIM member programs with 225 program director responses. Among these, 13 251 residents (70.2%) reported some training in caring for patients at risk for health disparities. Of residents who reported receiving training, 10 494 (79.2%) rated the quality as very good or excellent. These findings suggest that that despite the Clinical Learning Environment Review mandate and Accreditation Council for Graduate Medical Education required competencies for training in health disparities, relatively few internal medicine programs in the US provided educational curriculum. Additionally, the existence of health disparities curricula in internal medicine training programs was not associated with resident's perception of training or its quality.

A Multimodal Quality Improvement Curriculum for Pediatric GME Program Directors.

The 2016 Accreditation Council for Graduate Medical Education Clinical Learning Environment Review report identified knowledge gaps for quality in the clinical environment. It suggested quality improvement (QI) training is necessary to develop skills to improve health care quality. However, at the authors' institution, there is limited department-level QI mentorship and engagement, thus limiting QI experiences for residents and fellows. The authors developed pediatric graduate medical education program director (PD) proficiency in QI through a fellowship-focused QI project. PDs underwent an 18-month QI curriculum consisting of focused online QI education, a half-day workshop, additional QI didactic sessions, project presentations, and individual QI coaching. QI knowledge in 9 domains and participants' confidence were assessed. Participants' self-perceived confidence and skills increased by at least 20% in most domains. Overall, PDs felt prepared to help with their fellows' future QI projects. Fellowship-focused QI projects and individual coaching were key to course engagement.

A resident-led initiative to improve patient safety event reporting in an internal medicine residency program

ABSTRACT Background Despite the Clinical Learning Environment Review’s recommendations of their use, patient safety event reporting systems are underutilized by residents. Objective We aimed to identify perceived barriers to event reporting amongst internal medicine residents and implement a targeted quality improvement initiative to address the identified barriers and increase overall resident event report rates. Methods A total of 94 Internal Medicine (IM) residents participated in the educational intervention in 2018. We measured residents’ perception of barriers to event reporting and employed the results of the questionnaire to create a skill-based educational workshop. We conducted the plan-do-study-act model to test a structured educational intervention and its effectiveness on pre-post IM residents’ event report rates and compared it to report rates of Non-Internal Medicine (Non-IM) residents. Additionally, we assessed pre-post intervention knowledge, skills, and attitudes in event reporting. Results 94/94 (100%) of IM residents had a significantly higher median percent of patient safety event reporting when compared to pre-intervention (23.6% compared to 5.88%, p-value = 0.0030) and when compared to Non-IM residents (23.6% compared to 5.31%, p-value = 0.0002). Residents performed better on the post-test compared to the pre-test (90% compared to 30%, p-value = 0.0001) for knowledge. 100% of the critical action items were completed and 90% of participants reported their perception of the event reporting process improved. Conclusions By elucidating common reasons why residents are not reporting patient safety events, a specific intervention can be created to target the identified impediments and improve resident event reporting. Abbreviations IM: Internal Medicine IM; Non-IM: Non-Internal Medicine; IOM: Institute of Medicine I; ACGME CLER: Accreditation Council for Graduate Medical Education Clinical Learning Environment Review; GME: Graduate Medical Education; IRB: Institutional Review Board; PDSA: Plan, Do, Study, Act

IMPACT OF A STRUCTURED QUALITY IMPROVEMENT FRAMEWORK ON PROJECT OUTPUT IN A CARDIOLOGY FELLOWSHIP PROGRAM

Healthcare Quality Improvement (QI) is a key component of the Clinical Learning Environment Review(CLER) Program of the Next Accreditation System of the Accreditation Council of Graduate Medical Education (ACGME). Meaningful participation in Quality Improvement can be a challenge in cardiology

A Novel, Web-Based Quality Improvement Platform to Address ACGME CLER Requirements.

In 2014, the Accreditation Council for Graduate Medical Education (ACGME) formally mandated trainee (resident and fellow) participation in health care quality improvement (QI) projects as one of the Clinical Learning Environment Review (CLER) Pathways to Excellence. Subsequent national reviews showed large variations in how QI education is conducted, as well as a significant mismatch between educational and organizational goals. We developed a web-based platform to engage trainees in QI that better aligned with best practice methodology and matched identified institutional priorities. A needs assessment survey was distributed to trainees to understand the obstacles to compliance with ACGME QI requirements. Based on the results, a web-based clearinghouse, called the QI Platform, was developed and launched in July 2016, and utilization was analyzed in February 2019. A total of 196 of 440 needs assessment surveys (45%) were completed. Themes extracted from surveys to identify barriers in QI participation included difficulties designing projects, lack of mentorship or expert support, and difficulty engaging an interprofessional team. Over 2.5 years, 151 projects were registered on the platform. Of these, 17 (11%) were collaborative entries. At the time of analysis, 166 of 437 trainees (38%) were listed as participants in active QI projects. A total of 22 projects were archived as complete, and 68 incomplete projects were reassigned to the "Ideas" section as works in progress after lead trainee graduation. An institutional QI Platform clearinghouse for GME QI projects was feasible to develop and maintain, and it appeared acceptable to most GME programs and trainees for recording and tracking QI projects, and linking these to hospital QI priorities.

General Internists as Change Agents: Opportunities and Barriers to Leadership in Health Systems and Medical Education Transformation.

Health systems are increasingly engaging in mission development around the quadruple aim of patient experience of care, population health, cost of care, and work-life balance of clinicians. This integrated approach is closely aligned with the education principles and competencies of health systems science (HSS), which includes population health, high-value care, leadership, teamwork, collaboration, and systems thinking. Influenced by health outcomes research, the systems-based practice competency, and the Clinical Learning Environment Review, many medical schools and residency programs are taking on the challenge of comprehensively incorporating these HSS competencies into the education agenda. General internal medicine physicians, inclusive of hospitalists, geriatricians, and palliative and primary care physicians, are at the frontlines of this transformation and uniquely positioned to contribute to and lead health system transformation, role model HSS competencies for trainees, and facilitate the education of a new workforce equipped with HSS skills to accelerate change in healthcare. Although GIM faculty are positioned to be early adopters and leaders in evolving systems of care and education, professional development and changes with academic health systems are required. This Perspective article explores the conceptualization and opportunities to effectively link GIM with healthcare and medical education transformation.

Developing Graduate Medical Education Partnerships in American Indian/Alaska Native Communities.

Developing Graduate Medical Education Partnerships in American Indian/Alaska Native Communities.