Patient safety and quality improvement: a 'CLER' time to move beyond peripheral participation

In the United States, the Accreditation Council for Graduate Medical Education (ACGME) has instituted a new program, the Clinical Learning Environment Review (CLER), that places focus in six important areas of the resident and fellow working and learning environment. Two of these areas are patient safety and quality improvement (QI). In their early CLER reviews of institutions housing ACGME-accredited training programs, ACGME has found that despite significant progress in patient safety and QI to date much work remains, especially when it comes to meaningful engagement of medical trainees in this work. In this article, the authors argue that peripheral involvement of trainees in patient safety and QI work does not allow the experiential learning that is necessary for professional development and the ultimate ability to execute performance that meets the needs of patients in contemporary clinical practice. Rather, as leaders in patient safety and QI have advocated since early in this movement, embedded and immersed experiences are necessary for learning and success.