A DPT student completed all on-campus didactic and integrated clinical education experiences during the first 2 years of the program. In the third year of the program, the student successfully completed the first 12-week full-time clinical experience in an outpatient orthopedic practice by achieving the prescribed advanced intermediate level on the CPI evaluation. The student began a second 12-week full-time clinical experience at an inpatient rehabilitation facility.

During the fifth week, the student and the CI reached out to the academic program’s DCE to discuss performance concerns. From that point forward, the DCE was in frequent contact via email and phone with the student, the CI, and the Site Coordinator of Clinical Education (SCCE). The DCE spoke at least twice a week with the student, and the phone calls included coaching on clinical reasoning, communication strategies, and self-reflection. The DCE received weekly updates from the CI by email and phone regarding the student’s performance in the clinic that week, areas of improvement, and areas of continued challenge. The DCE performed a site visit in week 8 that included observation of the student and CI during a patient encounter and during a post-encounter debriefing session. Following the site visit, the DCE, CI, SCCE, and student established a learning plan and specific learning objectives. Ultimately, the clinical experience was terminated in week 10 due to significant and ongoing concerns regarding safety and clinical reasoning. The student received a failing grade for the clinical education course.

The ACES framework was applied to this student’s case (Fig. 2). The analysis of impact, predictability, and modifiability within step 1 and step 2 revealed that student characteristics and academic curriculum considerations were the main contributing factors. There was a disconnect between the student’s knowledge and skills (negative impact) and the outcomes of the written and practical exams (positive impact). Further analysis of the framework revealed an opportunity for improvement around programmatic processes, including assessment of clinical reasoning, how students are matched to clinical sites, and how new faculty are onboarded and introduced to policies, procedures, and resources.

The action plan detailed in step 3 addressed the curriculum factors and programmatic processes. The curriculum committee and course directors reviewed the current assessment strategies in core coursework related to clinical reasoning. The DCE reviewed advising strategies and clinical site matching processes to address the concern that, in this case, the student and clinical site were not a good fit. Finally, the program leadership recognized a need for more specific faculty onboarding procedures, as well as gaps within the current policies and procedures related to management of student progression issues.

The use of the ACES framework within the authors’ academic program has resulted in a formalized mechanism to evaluate student failure situations and to describe programmatic outcomes at a more detailed level. The approach provides a needed mechanism to evaluate the clinical education program through a multifaceted approach that accounts for all stakeholders. The sample case is an example of how this process can result in avenues for greater academic-clinical partnership, as the RCA process may lead to collaborative efforts between academic and clinical stakeholders to address opportunities for program refinement.

The important impact of the ACES framework results from the action recommendations determined in step 3. The United States Department of Veterans Affairs National Center for Safety developed an ‘Action Hierarchy’ for RCA processes in 2001. This hierarchy categorizes action recommendations based on their effectiveness and sustainability, using the classifications of strong, intermediate, and weak [11]. The Institute for Healthcare Improvement advocates that recommendations from any RCA process should include at least one strong or intermediate-strength action [4]. When applying this hierarchy to the case described in this paper, the actions were found to fall in the intermediate and weak categories. Integration of this type of classification system into the final step of the ACES framework may result in more sustainable and impactful actions.

Further use of the framework and formalized study of its applicability are necessary to determine its effectiveness, reliability, and validity in consistently identifying the root problems in clinical education situations. This would include application of the framework within a variety of academic programs and clinical situations, potentially allowing for further refinement of the tool to maximize its effectiveness. The ACES framework also has the potential to be applied to other student situations beyond clinical education, resulting in a formalized and structured programmatic evaluation mechanism. However, applications in the didactic setting may require an altered version of the framework, as there are different influences, factors, and characteristics to consider in the classroom setting. Ultimately, the authors of the framework intend to utilize the framework in a multi-institutional study that aims to examine trends in clinical education situations across institutions.