CLEO Frequently Asked Questions (FAQs)

Committee Structure & Function

Q: What is the Committee on Learning Environment Oversight (CLEO)?

A: The Committee on Learning Environment Oversight (CLEO) is responsible for the review of student concerns regarding the learning environment and the development of action plans in response to episodes of alleged medical student mistreatment to prevent future occurrences.

Q: Who participates in CLEO meetings?

A: For UME: The committee is composed of faculty, medical students from the Professionalism Council, and administration that are dedicated to promoting a positive learning environment with a strong focus on specific and timely feedback and education. There are four medical students, one from each class, for full representation.

A: For GME: The committee is composed of faculty, GME trainees, and administration that are dedicated to promoting a positive learning environment with a strong focus on specific and timely feedback and education.

A: For R&PDT: The research trainee subcommittee consists of faculty co-chairs, graduate student, postdoctoral scholar, and administrative/staff leaders of graduate student and postdoctoral education. 

Potential Ad Hoc Members Include:

• Site Director/Program Director at an Affiliate Site

• Director of Behavioral Wellness Center and Faculty Wellness Program

• Staff Member

• Legal Counsel

Q: How often does the committee meet?

A: The committee has a reoccurring monthly meeting scheduled. If needed, ad-hoc meetings will be scheduled to address high volumes of mistreatment reports.

Q: What does the committee review at meetings?

A: The committee reviews Mistreatment Incident Reporting Forms (MIRF) to determine a triage level and recommended an action plan in accordance with the triage level. In addition, the committee reviews data from various sources regarding the learning environment.

Q: Do committee members have access to identifying information from MIRFs?

A: Committee members do not have access to names of individuals in MIRFs. Any name in a report is redacted. Committee members are required to sign a confidential agreement that requires they not discuss the details of reports with anybody outside of the committee.

Submitting A MIRF

Q: What types of incidents should be reported through the MIRF?

A: We encourage students to submit any incident they perceive shows lack of respect for the dignity of others and negatively impacts the learning environment. Examples would include abuse, psychological cruelty, discrimination and harassment. It is best to report if you are not sure. The committee reviews and addresses all concerns.

Q: Can I submit a patient safety concern through a MIRF?

A: We prefer that patient safety concerns not be submitted through the MIRF. It is important that patient safety concerns are addressed quickly by providing the clinical site the information in real time. If you have a patient safety incident to report, we recommend speaking directly with the site director/supervising attending to inform them of the incident. Additionally, patient safety concerns should be reported through the institutions reporting system, which are all linked within this Box folder. If patient safety concerns are submitted through the MIRF, they will be referred to the appropriate Designated Institutional Official (DIO) for review.

Q: How soon after the incident should a MIRF be submitted?

A: We encourage students to submit a MIRF as soon as possible, preferably the day of the incident. By doing so, CLEO leadership is able to triage the MIRF and allow for interim measures to be implemented, if needed. CLEO Co-Chairs are also able to notify course/clerkship leadership to monitor for any possibility of retaliation that might occur following the MIRF submission. However, MIRFs can be submitted at any time to be addressed by the committee.

Q: Can the MIRF be used to submit an incident that happened at an affiliate site?

A: All incidents of mistreatment that occur involving a DGSOM students should be formally reported through the Mistreatment Incident Reporting Form (MIRF). Regardless of the site, the committee will partner with the appropriate stakeholders to address concerns at affiliate sites.

Q: What is the difference between reporting via a MIRF vs. via the end-of-course evaluations ?

A: Students should report incidents of mistreatment using the MIRF. Feedback on teaching effectiveness should be reported on end-of-course evaluations. Further, by submitting an incident through the MIRF, students are provided with the options of reporting as an identified or anonymous reporter, versus the end-of-course evaluations which are only anonymous. Additionally, students are able to follow-up on a MIRF whether submitted anonymously or not. MIRFs are reviewed in real time and allow for immediate actions, whereas course evaluations are only reviewed at the conclusion of the evaluation period. Regardless, any comments submitted on evaluations in the learning environment open text field are reviewed by both CLEO members and course/clerkship leadership.

Q: Will a MIRF be shared with anyone beyond committee members?

A: Yes, MIRFs are often shared with the individual reported for the alleged mistreatment and/or with leadership. The report is shared so that there is an understanding of how the incident was perceived by the reporter. We recommend that reporters be professional when submitting a report considering the individual being reported will likely receive a redacted copy of the report. Any identifying information about the reporter is redacted.

Q: What happens when a report is referred to UCLA Title IX and/or UCLA Discrimination Prevention Office (DPO)?

A: If a report is referred to either office, they may contact reporters to ensure them that they are aware of their rights, and the resources available to them. In addition, you will have the option to formally submit a report through either office. For any meetings, reporters may be accompanied by an advisor and/or support person. It is the reporter’s choice on whether or not to move forward with a formal report through either office.

Q: Are reporters contacted after submitting a MIRF?

A: Reporters will only be directly contacted by CLEO Chairs, if deemed necessary. For example, CLEO Chairs may request to have a call if additional information is needed or if there is a concern for reporter safety. Reporters are always encouraged to reach out to CLEO leadership at any point should they want to discuss the report with someone.

Q: What are the steps taken by the committee after a MIRF is submitted?

A: The following steps are taken once a MIRF is submitted. 

1. The MIRF will be triaged by the CLEO Co-Chairs and CLEO staff member within 72 business hours of submission.
   1. If needed, the MIRF will be referred to the appropriate entities (Title IX or DPO) for further review during the triaging process.
   2. If the report raises patient safety concerns, the MIRF will be referred through the appropriate patient safety reporting mechanism. Reporter’s name will remain confidential.
   3. If needed, interim measures will be implemented to provide the medical student with a safe learning environment.
2. The MIRF will be added to the next monthly CLEO meeting for review.
3. Prior to committee meetings, all members are provided with a summary of the case along with a redacted version of the MIRF. Any identifying information about the reporter and the individual being reported is redacted.
4. During committee meetings, the case is presented by the CLEO Co-Chairs and discussion occurs to determine a triage level and an action plan to address the concerns.
5. The CLEO Co-Chairs will implement the action plan as determined by the committee.
6. All information regarding the case and actions taken are entered into the database for tracking purposes.

Following Up on a MIRF

Q: Can I follow up on the status of a MIRF I submitted?

A: Yes! The committee will provide relevant notes within Case IQ. Please follow these detailed instructions for accessing the status of a report you submitted. 

Q: Are reporters informed about the actions taken to address a report?

We understand that as a reporter there is an interest in wanting to know specific actions that are taken to address to a report. We are unable to share details about reports because of the need to protect the confidentiality of the reported individual’s personnel file. This benefits the process, and everyone involved by allowing CLEO to more effectively address mistreatment, by adhering to laws and policies that govern the protection of personnel files. 

Actions Taken in Response to a MIRF

Q: How long does it take for CLEO to act on a MIRF?

A: CLEO leadership reviews MIRFs within 72 business hours for initial triaging. If interim measures are needed, CLEO leadership will act on a MIRF prior to it being review by the committee formally. This is done for the safety of the reporter and other learners. If a MIRF does not require interim measures, the committee develops recommended actions at their monthly meetings. CLEO leadership will begin implementing the recommended actions after the meeting. CLEO addresses reports as quickly as possible to avoid incidents from reoccurring.

Q: What are the types of actions that CLEO can recommend to address reports?

A: There are several actions that CLEO can recommend to address a MIRF including but not limited to those listed below.

• Direct Feedback: Individuals can be provided feedback through a feedback meeting or via a letter from CLEO Co-Chairs. Feedback meetings are facilitated by CLEO Co- Chairs and/or Residency/Fellowship Program Directors.
• Individual Improvement Plan: Department leadership is responsible for developing an improvement plan for the individual reported and tasked with informing CLEO Co-Chairs about the plan.
• Enhanced Process/System: Designated individuals are tasked with reevaluating and changing processes to address concerns raised in a report. This action prevents further incidents of potential mistreatment from occurring.
• Monitoring Plan: Department leadership will be provided a timeframe for reviewing evaluations of the reported individual. Once the monitoring period has ended, department leadership will report back to CLEO Co-Chairs with their findings.
• Individual removed from learners or learners removed from individual.
• Administrative Leave/Investigation: Vice Dean for Faculty and Department Chairs facilitate actions associated with placing an individual on administrative leave and conducting a thorough investigation.
• Feedback to Group: Reports that raise concerns with a group will be provided feedback by leadership.

Q: How does the committee determine action plans?

A: The committee assigns a triage level to all cases of mistreatment on a N/A or 0-3 scale. The following are action plans determined that are assigned based on the triage level.

• Level 0: The incident was determined to not have met the definition of the AAMC for mistreatment. Nonetheless, the committee recognizes that the behavior had a negative impact on the learning environment and/or reporter, which requires an action. The CLEO Co-Chairs will provide the faculty member with a letter outlining the impact that the reported behavior created on the learning environment. If the individual reported is a resident and/or fellow, the residency/fellowship program director is tasked with providing the trainee with feedback. 
• Level 1: The incident was determined to have meet the definition of the AAMC for mistreatment. The incident was not deemed to be egregious and was the first reported incident for the individual reported. The CLEO Co-Chairs will arrange a meeting with the faculty member to review a redacted version of the MIRF and to provide feedback. If the individual reported is a resident and/or fellow, the residency/fellowship program director is tasked with providing the trainee with feedback.
• Level 2: The incident was determined to have met the definition of the AAMC for mistreatment. The incident was of higher severity than a Level 1 or was a repeat incident for the individual reported. The CLEO Co-Chairs will communicate with the appropriate departmental leadership to request feedback and recommend appropriate action plans be provided to the faculty member or trainee.
• Level 3: The incident was determined to have met the definition of the AAMC for mistreatment. The incident was egregious or there is an observed pattern of mistreatment. The CLEO Co-Chairs will contact the Vice Dean for Faculty and Department Chair to notify them of the incident. CLEO Co-Chairs provide recommended actions and Leadership is responsible for enacting a remediation plan to address concerns.

Q: Are student performance evaluations affected if a report is submitted while a student is actively on a rotation?

A: Submitting a MIRF does not void a student performance evaluation (SPE). If a student is actively rotating, course leadership will be contacted to request they thoroughly review SPE’s to ensure there is no retaliation.

Student to Student Reports

What steps are taken if a medical student is reported through a MIRF?

A: If there are any concerns that the MIRF identifies a potential violation of the UCLA Student Conduct Code, the concern is shared with the Associate Dean for Student Affairs and forwarded to the UCLA Student Conduct Office in Murphy Hall for review. If there are any concerns that the MIRF identifies a potential violation of the DGSOM Professionalism Policy or Honor Code, or the UCLA Health Code of Conduct, the concern is shared with the Associate Dean for Student Affairs and forwarded to the DGSOM Committee on Academic Standing, Progress and Promotion (CASPP) for review.

What steps are taken if a Resident is reported through a MIRF?

A: If there are concerns that the MIRF identifies a potential violation of the mistreatment policy, the concern is reviewed by the CLEO GME Committee at their monthly meeting. 

What steps are taken if a Research or Post Doctoral Trainee is reported through a MIRF?

A: If there are concerns  that the MIRF identifies a potential violation of the UCLA Student Conduct Code, the concern is forwarded to the UCLA Student Conduct Office in Murphy Hall for review.

Reporter Confidentiality

Q: Are Mistreatment Incident Reporting Forms (MIRF) anonymous?

A: There is an option to submit a MIRF anonymously for reporters that prefer that option. The MIRF is not linked to mednet accounts to allow for anonymous submissions for those that choose this option. If the reporter includes their name and contact information, the reporter’s name will remain confidential with the CLEO Co-Chairs and CLEO staff. As mandated reporters, an exception would be when reports need to be referred to Title IX or DPO.

Q: If a report is submitted confidentially, who can see the reporter’s information?

A: CLEO Chairs and staff are the only individuals able to see the reporter’s information upon submission. However, CLEO leadership are all mandatory reporters and as such may be required to share the MIRF, including the reporter’s information, with the UCLA Title IX Office and/or Discrimination Prevention Office. If the Vice Dean for Faculty and/or patient safety offices are referred a report, then they may request the reporter’s information. CLEO leadership will reach out to the reporter prior to providing their information to these offices.

Q: If someone submits a MIRF on my behalf, would I remain confidential?

A: We highly encourage the DGSOM community to submit reports on behalf of others based on whether they personally witnessed an incident or if they were informed of an incident. It is up to the reporter as to whether they include the medical student’s information on the report. Regardless, CLEO follows the same process as they would with any report.

Q: What steps are taken to assess for retaliation?

A: DGSOM has zero tolerance for retaliation and any form of retaliation is considered an egregious form of mistreatment. When a medical student includes their name on a MIRF, CLEO leadership works with the Educational Measurement Unit to closely monitor student performance evaluations for any suggestion of retaliation. Likewise, if the student will continue on the same rotation, CLEO leadership will work with course/clerkship leadership to closely observe for any possible retaliatory behavior. If a medical student suspects retaliation, we encourage them to submit an additional MIRF so it can be triaged accordingly.