CLER Site Visit 2024: Supervision & Teaming

The 3-day Clinical Learning Environment Review (CLER) Site Visit at UWMC-ML is only weeks away, 30 July – 1 August 2024. It is important for you to be familiar with the 6 CLER domains. Previous messages have reviewed our progress in the first 2 CLER domains: Patient Safety and Health Care Quality, including Health Care Equity. This message concerns the two cross-cutting CLER domains: Supervision and Teaming.

SUPERVISION:

Residents and fellows are on the front line of all our hospital patient-care activities/procedures. Since they are all learners in our system, residents and fellows require progressive supervision throughout their educational program. In this way, learners can feel supported in their work to provide the safest quality patient care.

There is more to supervision than just providing oversight of trainees in the hospital. According to the CLER Pathways to Excellence 2.0, the Supervision rubric ensures that faculty provide trainees individualized, progressive autonomy while educating them about expectations for patient care. Like other hospitals, UWMC-ML is responsible for maintaining a supportive culture of safety through high-fidelity systems that can 1) verify which residents/fellows can perform which procedures and 2) detect and monitor workload vulnerabilities.

2019 CLER Feedback:

1. Perceptions of Adequate Supervision
   1. 70% of resident/fellows (R/F) responded that they were adequately supervised;
   2. 19% R/F responded that they are occasionally over supervised;
   3. 52% of program directors (PD) responded that residents are adequately supervised;
   4. 32% of PD responded that residents are occasionally over supervised;
2. Perceptions of Asking for Attending Assistance
   1. 35% of R/F occasionally felt uncomfortable asking an attending for assistance;
   2. 5% of R/F frequently felt uncomfortable asking an attending for assistance;
   3. 49% PD responded that R/F occasionally encountered an attending who made them feel uncomfortable asking for assistance;
3. Perceptions of Knowledge of Direct Supervision
   1. 88% of R/F indicated that they knew of what they were allowed to do without direct supervision;
   2. 67% of faculty indicated that they had an objective way to know procedures a particular R/F is allowed to perform without direct supervision;
   3. Few PD knew of an online intranet available for nonphysicians to access information about R/F procedural supervision requirements;

Four-year survey demonstrating that UW trainees believe they have appropriate levels of supervision

Goals:

1. Improve adequate supervision.
2. Educate faculty about levels of supervision and monitoring systems.
3. Reduce clinical burden on faculty so that they can better train residents/fellows and supervise them.

Status: In progress. We continue to work on ways for residents and fellows to raise concerns about supervision.

Monitoring:

The GME Institutional Supervision and Accountability Policy defines levels of supervision for residents, including supervision of procedures. Clinical staff must verify trainees’ required supervision levels per Joint Commission and ACGME requirements to ensure patient safety.

We use Annual Program Evaluations (APEs) to monitor supervision concerns reported by programs. The graph below shows the percentage of programs that indicated concerns about inadequate supervision over the past four academic years.

While most programs report no issues, we continually work on improving supervision to address the concerns raised.

We monitor the use of the GME Supervision Policy Template through the Annual Program Evaluations. The graph below illustrates the percentage of programs utilizing this template across different academic years.

This upward trend demonstrates our progress in standardizing supervision practices across programs.

To support the process of monitoring procedures that trainees can do, we revamped our Resident/Fellow Procedure Certifications lookup tool within MedHub (the Residency Management Tool) and enhanced program accessibility by building a resource page on how to maintain it. This tool was re-launched in August 2022 and is available for all program staff to maintain supervision levels accurately. More details can be found on our Procedure Certifications page.

Additionally, all program-level supervision policies are publicly available on our UW GME website.

TEAMING:

UW School of Medicine (SOM) is in the top 3% of sponsoring institutions by size in the country. UW GME has close to 1600 residents and fellows in 126 ACGME-accredited programs and 80+ non-accredited fellowships. One in every three UW Medicine physicians is a trainee in our health system and we train 65% of Washington state’s residents and fellows.

At some point in their training, nearly all of our trainees rotate through UWMC-Montlake (UWMC-ML) – the largest hospital in our consortium – where they work and interact with more than 5000 employees. Faculty and nurses at UWMC-ML have a constant role in supervising teams of care for the best patient outcomes.

The CLER Pathways to Excellence, version 2.0 emphasizes the multi-generational, multi-racial, interdisciplinary and interprofessional space which includes critical partnering with patients and their families to provide the best possible patient outcomes. CLER has identified a new focus area called Teaming which has replaced Transitions of Care. Teaming highlights the dynamic nature of the clinical care team and their interactions in providing patient care. The four focus areas of Teaming are:

1. Interprofessional collaboration – Encourages teamwork among all members for efficient and effective patient care and best outcomes.
2. Communication skills – Clear communication, active listening and mutual respect are skills that enhance coordination of safe patient care.
3. Leadership development – Fostering leadership skill among trainees and faculty ensures effective team management.
4. Conflict resolution – Addressing behaviors leading to conflict is critical. Teams should learn best ways to resolve disagreements and maintain positive work environments.

CLER Site Visits hope to encourage partnerships, stimulate dialogue to recognize successes and deficiencies in the system and, ultimately, change behaviors to sustain a safe, collaborative working environment.

2019 CLER Feedback: none – new category since our last site visit

Initial Goal: 50% of programs have activities that promote interprofessional teamwork.

Intervention(s):

GME education, including:

1. Annual UW GME New Resident and Fellow Orientation – stressed the importance of “teaming” during GME Patient Safety presentation to all incoming residents/fellows. Includes introduction to TeamSTEPPS communication skills.
2. GME Foundations Course in Quality Improvement & Patient Safety – includes an interactive TeamSTEPPs training session.
3. GME Leadership Skills Series for Residents and Fellows – a new offering this year for residents and fellows across programs, with session topics including team communication, difficult conversations, upstander training and supporting and empowering junior learners.
4. Annual fall e-Learning module on Patient Safety.

UWMC-ML Initiatives:

1. Structured Interdisciplinary Bedside Rounds on the Medicine services deliver coordinated, interdisciplinary care by doctors, pharmacists, residents, and nurses rounding together and answering questions regarding patient plans from each other and the patient.
2. Improving patient flow and transfers has allowed nursing and healthcare teams to work together to disposition patients to the right unit and correct clinical service, thus improving efficiency and acceleration of care.
3. TeamSTEPPS, used by certain teams, enhances teamwork and communication on the Labor & Delivery (L&D) unit through educational modules and protocols, setting expectations for huddles to improve safe patient care.
4. Morning Huddles – These include the attending surgeon, anesthesiology provider, OR nursing staff in the morning at 7:05 am or before the first case in the morning. This team huddle connects the key clinical team members for safe delivery of patient care.

Revised Goal: Increase the percentage of programs reporting implementing activities to promote interprofessional team work to 75%. Specific goals for Teaming will be identified based on CLER visit feedback.

Monitoring: GME required that all Annual Program Evaluations (APEs) for AY23 include information regarding activities that promote interprofessional teamwork. Sixty-seven percent (67%) of programs reported that they had at least one activity that promoted interprofessional teamwork.

For more information on CLER, please check out our GME CLER website.

Byron Joyner, MD, MPA
Vice Dean for GME and DIO