The New ACGME Duty Hour Standards and Their Implementation

1
The New ACGME Duty Hour Standards and Their
Implementation

• A Brief Overview of the New Standards and
• Some Concepts for Program Directors and
  Designated Institutional Officials

2
Background to the Duty Hour Effort

• Education and patient safety imperatives
• Heightened by changes in the clinical environment
  
• Patient safety, resident learning and well-being
• Calls for regulation
• Time spent on non-educational activities
• Inefficient support systems, coverage needs 

3
The Work Group

• September 2001 - ACGME charges Work Group to
  develop report and recommendations
• Review of literature literature
• Review of existing/proposed approaches
• Learning labs New York 405 rule, Canada, Europe
• AAMC policy guideline
• Conyers Bill and Corzine Senate counterpart (HR
  3236 S 2614), OSHA Petition, NJ Proposal
• Broad input from
• GME constituencies
• Experts (on sleep, education)

4
The ACGME

• June 2002 - Board of Directors receives Work
  Group report
• Vetting process for report, proposed preliminary
  standards language
• 170 pages of comments
• ACGME develops
• Proposed Program and Institutional Requirements,
  based on Work Groups report and comments
• Implementation and policy documents
• Impact statement 

5
The ACGME (continued)

• September 2002 Program Requirements Committee
  reviews draft duty hour standards
• Component of common standards
• Fall 2002 - Broad vetting process
• RRCs, appointing organizations, GME community,
  public
• February 2003 Final approval
• July 2003 - Implementation  

6
Basic Concepts

• Attention to duty hours is an imperative
• Standards must be defensible, practical and
  measurable
• Enforcement must be consistent, effective, fair
  and timely
• Communication re standards and enforcement must
  be clear and credible  

7
The Standards

• Call scheduled no more than every third night
• One (24-hour) day in seven free of patient care
• Limit of 80 duty hours per week
• Averaged over four weeks
• 24-hour limit on continuous duty, up to 6 hours
  for transfer, debriefing, didactic activities
• Defined by each RRC, includes required continuity
  clinics, first cases
• A 10-hour minimum rest between duty periods
• In-hospital hours during call from home count
  toward 80-hour limit 

8
The Standards (cont.)

• Program director must approve moonlighting
• Monitor effect on performance
• In-house moonlighting counted in weekly hours
• Education of residents and faculty about
  fatigue/its management
• Focus on preventive and operational
  countermeasures for sleep loss
• Support to reduce time spent on routine tasks
• Emphasis on rigorous and timely enforcement

9
One Size May Not Fit All

• Programs may apply for an increase up to 10 to
  the 80-hour limit
• Exceptions must have
• Sound educational rationale
• Endorsement of sponsoring institutions GMEC
• RRC review and approval
• Instituted for a fixed number of years
• On-going monitoring of effect
• In 2003, no exceptions to the 80-hour weekly
  limit at the specialty level 

10
Goals of the Effort

• Set minimum standards for all specialties
• RRCs with more restrictive standards will
  continue to enforce those requirements
• Create flexibility for exceptions that have a
  sound educational rationale
• Emphasize institutional accountability

11
Goals of the Effort (cont.)

• Program directors, institutions will have a
  larger role, more responsibility
• RRCs accountable for compliance
• Timely implementation, but acknowledge complexity
  via phasing
• Consistent enforcement of the new standards

12
Impact of the Standards

• There will be an effect
• It will not be the same for all programs in a
  given specialty
• It will vary significantly for different programs
  at the same institution
• There is a need to assess the organizational and
  culture changes resulting from the new duty hour
  standards 

13
The Existing Learning Laboratories

• New York State (15 percent of residents, 13 years
  of duty hour regulations)
• Internal Medicine (20 percent of residents 12
  years of ACGME limits on duty hours)
• European community
• Individual programs and institutions that have
  already implemented the standards  

14
Their Limitations

• Availability of data
• Lack of a uniform metric
• Perceived limited applicability (surgeons are not
  internists)
• Very little data from New York State and Canada
• Difference in GME time horizons in Europe limits
  applicability of European comparison
• Individual institutions are just beginning to
  release information on their efforts  

15
What Have They Shown Us

• New York State 54 of 82 teaching hospitals cited
  some degree of duty hour violation
• Resident hours a proxy for the learning
  environment
• Fewer hours often achieved by reducing
  educational activities
• Reducing duty hours can be done - It may not be
  easy  

16
Projecting the Costs

• 1989 estimate of added staffing costs for New
  York State hospitals 358 million (1)
• True cost difficult to estimate, must consider
• Differences in local costs for residents,
  replacements
• Time/opportunity costs for existing staff
• Reimbursement variations (fee-for-service,
  capitation)
• Variation in state practice, billing by
  non-physicians
• Offsets from reduced charges, length of stay,
  etc.
• Thorpe KE. House staff supervision and working
  hours. Implications of regulatory change in New
  York State. JAMA, 1990 263(23).

17
What Is Needed

• Rethinking the learning and working environment
• Comprehensive data on effect of the standards
• Start with simple questions
• Hours currently worked above the 80-hour limit
• Mechanisms needed to comply with the limits
• Local cost of compliance
• Possible means for financing costs in the
  constraints of the current system
• Adapted from Lewin/ICF 1989 study of California
  duty hours mandate  

18
What Is Needed (continued)

• Ensure accurate information collection
• Confidential reporting from residents, others
• Protection from retaliation, retribution
• Uniform metric to assess effect of standards
• Across different specialties, institutional
  models
• Organizational and accounting practices
• Strategies to optimize
• Patient care quality
• Education of residents and students
• Well-being and quality of life
•  

19
The Benefit of Models

• Innovative concepts for adoption/adaptation
• Broadly applicable approaches for responding to
  the duty hour limits
• Understand the interface between duty hours and
  overall learning environment
• Learn what constitutes optimal models for
• Resident education
• Institutional learning related to patient care
• Organizational and culture change  

20
Some Examples of Ongoing Work

• Boston Harvard ICU study and similar efforts
  funded by AHRQ
• Research on New York regulations
• Qualitative research on how to learn from changes
  in residency programs
• Institutional studies of the effect of reducing
  duty hours
• AAMC/IHI initiative  

21
Current ACGME Efforts

• Collecting Data on Resident Duty Hours via
• Duty ACGME resident questionnaire
• Site visit interview
• Annually interview 12,000 residents
• Confidentiality of resident sources
• Standardized questions on duty hours
• Standard set of data elements and a uniform
  metric
• Efforts to develop a broader uniform metric
• ACGME complaint management process  

22
Effect on Patient Care - Adding to Existing
Pressures

• The resident with the finger in dike model of
  care
• Shortages in mid-level professionals (PAs, NPs)
• Increasing role of faculty
• Pressures on faculty, especially junior faculty
• Competing demands, increasing bureaucracy
• High expectations, diminishing rewards vs.
  private practice
• Concurrent need to advance competency, enhance
  performance, promote diversity  

23
Effect on the Residents The Good, the Bad and
the Unknown

• Studies of the effect of reducing hours show
• No increase in hours of sleep Sleep is so
  important that residents forgo other activities
• No change in performance on standard tests
• More reported reading and self-learning
• More personal time
• Higher resident satisfaction

24
What Will Contribute to Success?

• Teaching residents how to use the time well
• Learning and using the science of sleep and its
  effect on performance
• Supportive leadership, knowledge about education
• Faculty, resident involvement in decision-making
  

25
What Will Contribute to Success?

• Ongoing assessment of compliance
• Study effect on patient care and learning
• Locally - Congruence between program and
  institutional activities
• Nationally Broad support from education
  community and public for the new standards