The Accreditation Council for Graduate Medical Education (ACGME) and ACGME International (ACGME-I) present the International Clinical Learning Environment Pathways to Excellence: Expectations to Achieve Safe and High-Quality Patient Care. This document is a tool for promoting discussions and actions to optimize graduate medical education (GME) and patient care. It frames each of the pathways and properties from the health system’s perspective, recognizing that health care organizations create, and are therefore primarily responsible for, the clinical learning environment (CLE). This focus emphasizes the importance of the interface between GME and the hospitals, medical centers, ambulatory sites, and other health care settings across the continuum of care that serve as CLEs. This document is an adaptation of the ACGME’s CLER Pathways to Excellence. As such, it is similar yet not identical to the US version. This document reflects the review and input of a working group of international GME leaders from ACGME-I-accredited Sponsoring Institutions. While the majority of properties contained in this document are identical to those in the ACGME CLER Pathways to Excellence Version 2.0, approximately one quarter were modified, and a few were deleted to make the document more applicable and acceptable across a wide range of international contexts. About the ACGME and ACGME International The ACGME is an independent, 501(c)(3) not-for-profit organization that sets and monitors voluntary professional educational standards essential in preparing physicians to deliver safe, high- quality medical care to all Americans. ACGME-I is an independent 501(c)(3) organization created by the ACGME in 2009. The Mission of ACGME-I is to improve health care by assessing and advancing the quality of resident physicians’ education through accreditation. ACGME-I protects the interests of residents and improves the quality of teaching, learning, research, and professional practice, with the ultimate goal of benefiting the public that its accredited programs and graduates serve. © 2025 Accreditation Council for Graduate Medical Education and ACGME International. ISBN: 978-1-945365-48-5 Citation: CLE Pathways International Working Group. International Clinical Learning Environment Pathways to Excellence: Expectations to Achieve Safe and High-Quality Patient Care. Chicago, IL: Accreditation Council for Graduate Medical Education and Accreditation Council for Graduate Medical Education International; 2025. doi: 10.35425/ACGME.0011 Summary publication: CLE Pathways International Working Group. International Clinical Learning Environment Pathways to Excellence: Executive summary. J Grad Med Educ (2025 in press).
Introduction
The World Health Organization (WHO) has long recognized inequities in patient safety and quality of care as challenges to achieving the goal of better health care for all.1,2 The WHO recognizes the role of workforce education as one of the strategic objectives in its global patient safety action toward eliminating avoidable harm in health care.3 The physician workforce is one of the key levers to improving health care. Resident and fellow physicians who work on the front lines of patient care need to be prepared to recognize patient safety events and intervene when appropriate, to champion performance improvement efforts, and to work effectively in interprofessional teams on systems-based issues. The next generation of the health care workforce needs the skills to be able to lead changes in health care organizations both large and small across the globe.
Background
This initial version of the International Clinical Learning Environment Pathways to Excellence document is based on a series of documents published by the ACGME.4-6 The ACGME’s CLER Program published the first CLER Pathways to Excellence document in 2014. At the time, the CLER Program launched a site visit process to explore the clinical sites that host US GME and provide formative feedback for improving the CLE in six cross-cutting Focus Areas, including patient safety and health care quality. The CLER Program created the initial and subsequent versions of the CLER Pathways to Excellence to serve as guidance to promote discussions and actions in these six cross-cutting Focus Areas to optimize the CLE for GME and patient care. Additionally, in the United States, the National Collaborative for Improving the Clinical Learning Environment noted that CLEs are shared educational experiences and developed a similar document to address learners across the health care professions.7 Globally, there is keen interest in improving the CLE. By adapting the work of the CLER Program, this document provides guidance that can resonate internationally as educational leaders engage in dialogue with the executive leaders of their CLEs to build or strengthen infrastructure and processes that optimize both learning and patient care. In each of the six CLER Focus Areas, there is a series of pathways and properties that are framed as expectations. Currently, these are neither requirements for ACGME-I accreditation nor are they intended to serve a regulatory function. They are a framework that can be used to initiate or deepen conversations among GME leaders and health care executives as they strive to optimize the clinical site’s ability to provide high-quality education and safe patient care. As noted above, CLEs are shared by many learners—both within medicine and across the health care professions. As such, the guidance within this document can be broadened to encompass resident and fellow physicians in non-accredited programs, as well as learners from other professions on the clinical care team.
DEVELOPING THE INTERNATIONAL CLINICAL LEARNING ENVIRONMENT PATHWAYS TO EXCELLENCE DOCUMENT
To adapt the CLER Pathways to Excellence for the international community, the leaders of the CLER Program and ACGME-I convened a working group composed of GME leaders (designated institutional officials or their designees) and organizational leaders in patient safety and health care quality improvement from Sponsoring Institutions accredited by or in dialogue with ACGME-I. Collectively, the document was informed by inputs from more than 40 participants from 22 Sponsoring Institutions/organizations across 12 countries, including Guatemala, Haiti, Jordan, Kenya, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Singapore, the United Arab Emirates, and Vietnam. To begin this work, the participants reviewed Version 2.0 of the CLER Pathways to Excellence document to determine if each of the properties in the six Focus Areas needed modification to be more applicable internationally. Participants responded to an initial survey review of the CLER Pathways 2.0 document (i.e., pathways and properties) by reviewing each property in the Pathways document and marking it “keep as written,” “modify,” or “delete.” The results of the initial review were then collated and used to inform small- and large-group discussions held both in person and online via videoconference. Overall, most of the properties in Version 2.0 of the CLER Pathways to Excellence document were determined to be applicable and did not require modification. Several rounds of iterative discussions and revisions were required to modify approximately one quarter of the properties. Participants reached consensus on the final version presented in this document.
USING THE PATHWAYS’ FRAMEWORK
The International Clinical Learning Environment Pathways to Excellence provides a framework for clinical sites to use in their continuing efforts to prepare the members of the clinical care team to deliver consistently safe, high-quality patient care. Central to the document is a series of pathways for each of the six Focus Areas, which are collectively essential to creating an optimal CLE. In turn, each pathway presents a series of key properties that CLEs, in collaboration with their GME leadership, can implement to optimize resident and fellow physicians’ engagement. For example, the Patient Safety Focus Area has defined pathways. The first is: PS Pathway 1: Education on patient safety Five properties are attached to this pathway—each designed to assess the GME connection to the structures and processes the CLE has put into place to promote safe, high-quality patient care. The first is: The clinical learning environment: a. Provides residents, fellows, and faculty members with interprofessional, experiential training on the principles and practices of patient safety. In total, this first version of the International Clinical Learning Environment Pathways presents six Focus Areas, 34 pathways, and 137 properties. The pathways and their properties cannot be achieved by GME leaders alone. To be successful, a close partnership is needed between GME leadership and the highest level of executive leadership at the clinical site. This guidance document is a tool to assist health care organizations in prioritizing and acting on opportunities to improve the CLE for resident and fellow physicians and—ultimately—patient care outcomes.
STRIVING FOR EXCELLENCE
The International CLE Pathways to Excellence is intended to accelerate conversations among educators, health care leaders, policy makers, and patients regarding the importance of continually assessing and improving the environments in which resident and fellow physicians learn and train, as well as the role of GME in promoting safe, high-quality patient care.
