PREPARING FOR THE CLER SITE VISITFOR BEN TAUB GENERAL HOSPITAL

1

• Overview the Clinical Learning Environment Review (CLER) program

• Discuss the concept of maintaining a “culture of readiness” across BCM clinical training sites

• Present specific resources available to Ben Taub General Hospital to promote readiness for site visits

• Delineate site-specific core knowledge across the six areas of focus in preparation for CLER site visits

Goals and Objectives

2

As residents and fellows pursue their training, it is essential that the clinical learning environment provides adequate resources and support to ensure their engagement and integration with the infrastructure of the training site.

The CLER Program is designed to provide formative feedback to graduate medical education (GME) leaders and the executive leadership of the clinical learning environments (CLEs) regarding housestaff integration and engagement across six areas of focus.

What is the Clinical Learning Environment Review (CLER) Program?

CLEs = Hospitals, Medical Centers and Ambulatory

Care sites

3

1. What is the clinical learning environment’s (CLE’s) infrastructure for addressing the six focus areas?

2. How integrated is the GME leadership and facultywithin this infrastructure?

3. How engaged are the resident and fellow physicians in working with the CLE’s infrastructure to address the six focus areas?

4. How does the CLE determine the success of its efforts to integrate GME into its infrastructure?

5. What areas has the CLE identified as opportunities for improvement?

Site visits structured to gather evidence to answer five key questions

To establish a baseline, initial CLER site visits have focused principally on the first three questions.

4

• Team of 2-3 site visitors will spend 2-3 days at hospital

• Typically occur in an 18-24 month cycle

• Intentional short notice (approximately 2 weeks)

• Limited advance materials to provide- Organizational charts

- Policies: Supervision, Duty Hour, Care Transitions

- Patient Safety and Healthcare Quality protocols/strategies

- Quality & Safety Committee membership rosters (identifying housestaff members)

- Participating Site’s Quality Strategy

- DIO’s Annual Report

- Times/Locations of Hand-Offs

CLER Site Visits

5

• Opening and closing meetings with CEO and DIO and other leaders (CMO, CNO, Chair and resident member of GMEC, COO, CFO)

• Interviews with CLE’s leadership in Patient Safety, Healthcare Quality and informatics

• Group interviews of residents and fellows, core faculty, and program directors using Audience Response System

• Interviews with broad range of clinical staff members (residents and fellows, faculty members, nurses, pharmacists, social workers and other health care professionals) while on walk rounds

• Observations of patient hand-offs at various services

Meeting Participants

6

Schematic Flow of CLER Site Visit

7

• Group Meetings with audience-response system (ARS)- Approximately 50 questions posed to composite groups of housestaff, faculty and

program directors

- Expected quick response, in compressed time period~30 seconds/question

- Live polling software with results immediately displaced

- Answer to the best of your ability; likely no time for clarifying questions

- Resources: Likely survey questions have been distributed in advance; please review these questions and consider your potential responses in advance.

• Walk Rounds- Observation of handoffs and other aspects of patient care delivery

- They will ask you questions during times which do not interrupt active care delivery

- Continue your daily work

Know the spirit of what they are asking

Your responses should be reflective of your daily work and study

- Resources: Know your current process for transitioning the care of patients

Know the spirit of what they are asking

Reflect upon the activities of your daily work and study

How will you interact with the Site Visitors

8

• An oral report to leadership at end of visit

• A written narrative report summarizing the site visitor’s observations

• A report that will provide national aggregated and de-identified data displayed along a continuum of progress toward achieving optimal resident and fellow engagement in the six focus areas

Three types of formative feedback from CLER Site Visits

9

Key Opportunities: Engage and Integrate

Based on the results from the first visit, there are opportunities for Service Chiefs

to consistently include GME, faculty, residents/fellows and other clinical staff

in quality, patient safety and performance improvement activities and education

10

Maintaining a Culture of Readiness:

11

• CLER is about integration and engagement.

• Without effective clinical learning environments, residents and fellows cannot receive the training and education they need. CLER matters to ALL of us.

• Housestaff, faculty, staff and leadership should be on the same page.

• Be thoughtful about how you are achieving these goals every day in your work and study.

ALL of the above applies to:

Faculty, Residents & Fellows and Other Clinical Staff...

KNOW YOUR ROLE.

Maintaining a Culture of Readiness:

12

• CLER Program primers for Leaders/Administration, Faculty, Residents and Fellows, and Other Clinical Staff

• BTGH specific key information for each of the six focus areas (this document)

• ARS Survey Questions

• The BCM CLER Readiness Website is your “one stop shop” access for CLER-related background, training, links to portals, policies and procedures, etc. <https://www.bcm.edu/education/graduate-medical-education/cler>

• The Harris Health intranet contains important information about Ben Taub General Hospital, including quality and patient safety priorities, how to report errors and our process.<https://www.harrishealth.org/en/pages/employees.aspx>

Resources to Prepare for Site Visits

13

Patient SafetyHealth Care

QualityCare Transitions

SupervisionDuty Hours,

Fatigue Mgmt & Mitigation

Professionalism

Six CLER Focus Areas

14

Domains of Knowledge

Each member of the the clinical learning environment should understand the core

domains of knowledge for each of the six

CLER focus areas, as it pertains to your role.

15

• What are the Ben Taub General Hospital strategic priorities for healthcare quality?

1. Time-out

2. Hand hygiene

3. Just Culture

• What policies and procedures exist at Ben Taub General Hospital pertaining to healthcare quality?

1. Healthcare Quality: Harris Health System Quality Manual

2. Healthcare Disparities: Service First principles (F-Friendliness I-Integrity R-Responsibility S-Satisfaction T-Teamwork)

• Describe education and interprofessional practice pertaining to healthcare quality at Ben Taub General Hospital.

1. Education occurs primarily through orientation, online modules and conferences

2. Housestaff, faculty and staff participate in the Quality Review Council (QRC).

a. The QRC allows housestaff to be included in QI education and activities at Ben Taub General Hospital

b. Subcommittees of the QRC include Pain Management, Timeout, Hand Hygiene, Consent and HAPUs); residents are included in QI education and activities through these subcommittees

• Describe reporting and monitoring pertaining to healthcare quality at Ben Taub General Hospital.

1. Routine reports by the QRC to faculty, housestaff and other clinical staff facilitate reporting and monitoring.

• Describe continuous quality improvement initiatives pertaining to healthcare quality at Ben Taub General Hospital.

1. M&M conferences, debriefs after critical events, PDCA projects in your unit are examples

2. Housestaff involved in the QRC and/or BCM Housestaff Quality and Safety Council are involved in helping to improve quality and safety.

Focus Area 1: Healthcare Quality

16

System Performance Improvement Projects January 2016 – December 2016

Project DescriptionTime Out A “ time out”, before starting the procedure, to

confirm that the correct patient, site and procedure have been identified, and that all required documents and equipment are available and ready for use.

Hand Hygiene Hand hygiene practices are key prevention measures in healthcare settings and can prevent potentially fatal infections from spreading from patient to patient.

Just Culture Creating an open, fair and learning culture designing safe systems and managing behavioral choices. Just culture recognizes that human error and faulty systems can cause a mistake, and encourages the investigation of what led to the error instead of an immediate rush to blame a person.

January 2016 to December 2016

17

• What are the Ben Taub General Hospital strategic priorities for patient safety?

1. Time-out

2. Hand hygiene

3. Just Culture

In the just culture at Ben Taub General Hospital, EVERYONE is empowered to speak up and is responsible for reporting adverse events. Think of an adverse event you have reported.

• What policies and procedures exist at Ben Taub General Hospital pertaining to patient safety?

1. Patient Safety Plan 2016

• Describe education and interprofessional practice pertaining to patient safety at Ben Taub General Hospital.

1. Education occurs primarily through orientation, online modules and conferences; Incident reporting guidelines and in-service exists

2. Time-outs: Time-outs must routinely be conducted before procedures and when appropriate, should include residents and fellows. Think of a time-out in which you have participated.

• Describe reporting and monitoring pertaining to patient safety at Ben Taub General Hospital.

1. Events reviewed by QRC or through RCAs.

a. You may receive feedback about reported events through your clinical teams, service line chiefs or general education initiatives.

• Describe continuous quality improvement initiatives pertaining to patient safety at Ben Taub General Hospital.

1. Housestaff involved in the QRC and/or BCM Housestaff Quality and Safety Council are involved in helping to improve quality and safety.

Focus Area 2: Patient Safety

18

• Adverse events are reported through the Electronic Incident Reporting System (EIRS).- Go to the Harris Health intranet

<https://www.harrishealth.org/en/pages/employees.aspx> and follow the links to E-Incident Reporting to report an adverse event

- RESIDENTS and FELLOWS: BAYLOR RISK MANAGEMENT can help if you have been involved in a serious safety event.

Focus Area 2: Patient Safety (continued)

19

• Open Internet Explorer on Harris Health PC

• Select E-incident reporting in tab on the left hand side

• Log in with Harris Health ID and password (same as Windows login)

Harris Health REPORTING(BTGH / Community clinics)

20

• What are the Ben Taub General Hospital strategic priorities for supervision?

1. Ensuring that housestaff performing procedures received the appropriate degree of supervision

2. We are ALL responsible for making sure that appropriate supervision occurs for trainees.

RESIDENTS and FELLOWS: You MUST speak up if you are concerned about the level of supervision you are receiving.

FACULTY and STAFF: You MUST speak up if you are concerned about the level of supervision a trainee is receiving.

• What policies and procedures exist at Ben Taub General Hospital pertaining to supervision?

1. Graduate Medical Education Policy 27.5.10 - Responsibilities of Programs

• Describe education and interprofessional practice pertaining to supervision at Ben Taub General Hospital.

1. Education occurs primarily through orientation, online modules and conferences

2. CACTUS system provides a means through which other clinical staff can verify the credentialing status of housestaff

• Describe reporting and monitoring pertaining to supervision at Ben Taub General Hospital.

1. Training programs, under the direction of the Program Director, facilitate monitoring and reporting for trainee procedures

• Describe continuous quality improvement initiatives pertaining to supervision at Ben Taub General Hospital.

1. Housestaff, faculty and staff participate in the Quality Review Council (QRC).

a. The QRC allows housestaff to be included in QI education and activities at Ben Taub General Hospital.

Focus Area 3: Supervision

21

• What are the Ben Taub General Hospital strategic priorities for care transitions?

1. Implementation of a standardized framework for handoff practices, across specialty, discipline, floor or unit

• What policies and procedures exist at Ben Taub General Hospital pertaining to care transitions?

1. Graduate Medical Education Transitions of Care Policy

• Describe education and interprofessional practice pertaining to care transitions at Ben Taub General Hospital.

1. Education occurs primarily through orientation, online modules and conferences

2. Know your service’s method of care transitions

3. Know that a standardized framework is forthcoming (I-PASS)

• Describe reporting and monitoring pertaining to care transitions at Ben Taub General Hospital.

1. Faculty are expected to periodically observe trainee handoffs.

• Describe continuous quality improvement initiatives pertaining to care transitions at Ben Taub General Hospital.

1. Housestaff involved in the QRC and/or BCM Housestaff Quality and Safety Council are involved in helping to improve the care transitions process.

Focus Area 4: Care Transitions

22

23

• What are the Ben Taub General Hospital strategic priorities for duty hours and fatigue management & mitigation?

1. Providing housestaff with effective education, strategies and tools to manage fatigue to ensure safe care delivery

• What policies and procedures exist at Ben Taub General Hospital pertaining to duty hours and fatigue management & mitigation?

1. ACGME Common Program Requirements

2. Graduate Medical Education Policy-Duty Hours

• Describe education and interprofessional practice pertaining to duty hours and fatigue management & mitigation at Ben Taub General Hospital.

1. Education in fatigue takes place during orientation, conferences, online training and through day to day reminders.

2. If you are tired and fatigued at Ben Taub General Hospital, you can

a. Take a nap

b. Access caffeine

c. Request a cab ride home

d. Seek counseling/support

• Describe reporting and monitoring pertaining to duty hours and fatigue management & mitigation at Ben Taub General Hospital.

1. Training programs, under the direction of the Program Director, facilitate monitoring and reporting for trainee procedures

• Describe continuous quality improvement initiatives pertaining to duty hours and fatigue management & mitigation at Ben Taub General Hospital.

1. Self-regulate, support colleagues, escalate when appropriate.

Focus Area 5: Duty Hours and Fatigue Management & Mitigation

24

• What are the Ben Taub General Hospital strategic priorities for professionalism?

1. Service First principles (F-Friendliness I-Integrity R-Responsibility S-Satisfaction T-Teamwork)

• INTEGRITY, RESPECT, COLLEGIALITY; there is NO tolerance for mistreatment or compromise of these values.

• What policies and procedures exist at Ben Taub General Hospital pertaining to professionalism?

1. Service First principles (F-Friendliness I-Integrity R-Responsibility S-Satisfaction T-Teamwork)

• Describe education and interprofessional practice pertaining to professionalism at Ben Taub General Hospital.

1. Education in professionalism takes place during orientation, conferences, online training and through day to day reminders.

• Describe reporting and monitoring pertaining to professionalism at Ben Taub General Hospital.

1. Report concerns about professionalism through the BCM Integrity Hotline. Access through the BCM CLER Readiness Website.

2. Who can you talk to if you have any professionalism concerns about a colleague, supervisor or any one else?

a. RESIDENTS and FELLOWS: Chief Resident, Program Director, GME office/Ombudsman, a trusted faculty member

b. FACULTY: Department Chair, Chief of Staff

c. STAFF: Unit director/manager, Human Resources

• Describe continuous quality improvement initiatives pertaining professionalism at Ben Taub General Hospital.

a. You may receive feedback about reported events through your clinical teams, service line chiefs or general education initiatives.

Focus Area 6: Professionalism

25

• The CLER Program is designed ensure that the clinical learning environment provides adequate resources and support to the engagement and integration of housestaff with the infrastructure of the training site.

• Be thoughtful about how you are achieving these goals every day in your work and study.

• There are several available resources including the support maintaining a culture of readiness.

• Each member of the clinical learning environment should understand the core domains of knowledge for each of the six CLER focus areas, as it pertains to your role.

ALL of the above applies to:

Faculty, Residents & Fellows and Other Clinical Staff...

KNOW YOUR ROLE.

Summary

26