The ACGME defines each CLER focus area in CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment (Executive Summary). Journal of Graduate Medical Education: September 2014, Vol. 6, No. 3, pp. 610-611.
S Pathway 1: Education on supervision
S Pathway 2: Resident/fellow perception of the adequacy of supervision
S Pathway 3: Faculty member perception of the adequacy of resident/fellow supervision
S Pathway 4: Roles of clinical staff other than physicians in resident/fellow
S Pathway 5: Patients and families and graduate medical education supervision
S Pathway 6: Clinical site monitoring of resident/fellow supervision and workload
The findings illustrate the inherent difficulty that CLEs have in achieving the appropriate level of supervision, an issue that is necessarily complicated by the need for different degrees of supervision at different stages of training.
Over-supervision was identified as a challenge in many CLEs. Over-supervision of residents and fellows can have the negative consequence of producing physicians who are unprepared for independent practice. Billing requirements, payment policies, and regulatory and accreditation rules may be influencing CLEs and residency programs to place significant restrictions on the amount of patient care that residents and fellows can perform without direct supervision.
With regard to under-supervision, the findings suggest that often the only interface between GME and the hospital or medical center's patient safety and health care quality department happens after a major patient safety event has occurred. Patient safety and quality departments could benefit from working with GME to develop proactive monitoring of physician learners. Any proactive monitoring system would be likely to be underutilized unless the CLE clearly communicates expectations regarding use of this information in the daily workflow of clinical care for all members of the clinical team.
Comprehensive solutions for appropriate supervision of, and delegation of authority and responsibility to, residents and fellows within CLEs require ongoing attention and monitoring. This responsibility, while centered within GME, needs to include regular review by the executive leadership of the CLEs.
Issues of appropriate supervision are seldom simple and require careful oversight by faculty members. Due to the complex nature of clinical care, other members of the clinical team need to be involved in assuring adequate supervision in a role that is supportive to faculty members and their residents and fellows. Such support requires information on the need for and type of supervision for each resident and fellow to be available to faculty members, supervising residents and fellows, and non-physician clinical staff (e.g., nursing) in an accessible and timely manner. It also requires that such information is reliably being used to support clinical care.