ACGME (CLER) Clinical Learning Environment Review

The current pandemic has taught us that the healthcare system can’t be taken for granted. The doctors and medical researchers have been working day and night to ensure patient safety. It hasn’t been easy for everyone to keep pace with the rapidly evolving health care environment.

A survey conducted by the American Hospital Association found that the new physician workforce is ill-equipped in areas like communication, teamwork, system-based practices, etc. Thus, there was a need for a feedback mechanism or regulations which can help improve the health care system.

This need has been a patient’s demand even before when the pandemic began. Recognizing this gap and weakness, the ACGME council has designed the CLER Program to provide periodic feedback to medical centers, health systems, teaching hospitals, etc., in areas like patient safety and health care quality. In this article, we have tried to cover different aspects of clinical learning environment review. Let’s dive into the details right away.

Clinical Learning Environment Review (CLER) ACGME

Clinical Learning Environment Review (CLER)

Recognizing the public’s need for quality improvement in healthcare systems, the ACGME has implemented the CLER program. CLER is short for Clinical Learning Environment Review. Under this program, the ACGME plans to address issues in six focus areas: Patient Safety, Health Care Quality, Care Transitions, Supervision, Well-Being, and Professionalism.

Some aspects of the ACGME CLER program are:

  • Integration of residents into an institution’s patient safety programs to demonstrate impact.
  • Oversight of transitions in care.
  • Integration of residents into an institution’s quality improvement program to reduce health care disparities, and monitor impact.
  • Implementation and monitoring of supervision policies.
  • Monitoring of duty hours, fatigue management, and mitigation policies.
  • Training, awareness, and monitoring of professionalism.

5 key questions that every institute has to answer during the CLER visit are:

  1. What areas of improvement have been identified by the hospital or medical center?
  2. How does the hospital or medical center determine success to integrate GME into its clinical setting?
  3. How engaged are residents and fellows?
  4. How is the hospital or medical center’s infrastructure addressing the six focus areas?
  5. How integrated is GME leadership and faculty in improving the six focus areas?

Each sponsoring institution has to undergo a CLER site visit every 24 months to maintain the accreditation. After completion of each visit, the CLER team meets with the organization’s leadership to share its feedback.

The formative feedback received from this program’s implementation should improve how clinical sites and fellow physicians provide health care solutions to patients.

Also Read: ACGME Resident Operative Log Guidelines

CLER visit scheduling

The CLER team does short-notice visits to assess the performance of medical institutions. Generally, a 10-day prior notice is given to the Sponsoring Institution’s designated primary contact. The CLER field representatives visit only one participating site per sponsoring institution.

But the site visitors can choose to visit other facilities if those are in the vicinity of the audited site.

The presence of both the DIO and the Chief Executive Officer of the participating site is mandatory to participate in the meetings. If the participating site isn’t able to confirm their presence within 24 hours of contact, the institution gets a ‘pass’. Up to 3 passes are allowed.

On the fourth and final attempt, if the participating site fails to acknowledge the audit request, a request will be sent to the ACGME Board of Directors to confer upon the Sponsoring Institution the status of Administrative Probation. More details can be found in the policy document.

CLER blackout weeks can be used to optimize the scheduling of CLER visits by avoiding dates when the required attendees have a conflict. Blackout weeks were established to improve success in scheduling CLER visits. To request blackout weeks, the institutional coordinators can follow below steps:

  • Log in to ADS. Its link is available in the top right corner of the ACGME website.
  • Click on the ‘CLER’ tab on the right side of the webpage.
  • Click on the ‘Blackout Dates’ icon in the Blackout Dates Maintenance section.
  • The list of blackout weeks will be displayed institution-wise.

CLER Pathways to excellence

The CLER Pathways to Excellence is developed by the ACGME’s CLER Evaluation Committee. This committee provides guidance on all aspects of CLER program development.

The members are chosen based on their expertise in areas of patient care, GME, patient advocacy, health care quality, and hospital administration. This committee’s main goal is to ensure that safe high-quality patient care is provided to all US citizens.

For each of the six areas, a series of pathways is defined to create an optimal clinical learning environment. To give you an example, the patient safety vertical has seven pathways defined, the first being, ‘Reporting of adverse events, close calls ‘.

To read more details about the pathways defined for all the verticals, you can access the documented pdf at this link.


The Accreditation Council for Graduate Medical Education (ACGME) is the body responsible for accrediting all graduate medical education programs for physicians in the United States. Some of these programs include fellowships, internships, residencies, etc.

The ACGME also confers recognition on additional program components and dedicates resources to initiatives addressing areas of import in graduate medical education. It is a non-profit private council that is committed and dedicated to improving health care and medical education in the United States.

In the 2019-2020 academic year, there were approximately 865 ACGME accredited institutions that sponsored around 12,000 residency and fellowship programs in 182 specialties. Accreditation is achieved through a voluntary evaluation and review process based on published accreditation standards.

A review committee consists of volunteer specialty experts from the field that the Sponsoring Institution is requesting for accreditation.


Proper function of health systems is critical for a patient’s safety and timely treatment. The CLER framework highlights the importance of nurses, faculty members, and executive leadership working in the healthcare sector.

The clinical learning environment must be an integral part of the healthcare industry to flag and avoid patient safety events. Hopefully, this article has been able to shed some light on the CLER program. If you still have some doubts or questions, you can reach out to us anytime.

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