Accreditation Council for Graduate Medical Education
Discussion of Draft Duty Hour
Standards
Clinical Chairs-July 15, 2010
E. Stephen Amis, Jr., MD
Co-chair, Duty Hour Task Force
History & Background
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1987—Bell Commission and NY State 405 regulations
1999—Institute of Medicine Report: “To Err is Human”
2003—ACGME Duty Hours standards go into effect
2007—Congress asked AHRQ to investigate resident
work hours (legislative oversight threatened)
• 2008—IOM Report: “Resident Duty Hours”
• 2009—ACGME Duty Hour Task Force formed
Duty Hours Task Force
E. Stephen Amis Jr., MD - RRC Chair, Radiology, CRC Chair – Co-Chair
Susan Day, MD - Ophthalmology. Board Chair, ACGME – Co-Chair
Thomas J. Nasca, MD, MACP - Nephrology. CEO, ACGME – Vice Chair
Paige Amidon – ACGME Board Director, Public Director
Jaime Bohl, MD – CRCR Resident Member, Colon and Rectal Surgery
Lois Bready, MD – former RRC Chair, Anesthesiology
Ralph Dacey, Jr., MD – RRC Chair, Neurosurgery
Rosemarie Fisher, MD – RRC Chair, Medicine. CRC Vice Chair
Timothy Flynn, MD – Vascular Surgery. ACGME Board Chair-Elect
Stephen Ludwig, MD – RRC Chair, Pediatrics
Robert Muelleman, MD – RRC Chair, Emergency Medicine
Janice Nevin, MD, MPH – former RRC Chair, Family Medicine
Meredith Riebschleger, MD – CRCR Resident Member, Pediatrics
William Walsh, MD, MPH – ACGME Board Director, Pulmonary & Critical Care
George Wendel, Jr., MD – RRC Chair, Obstetrics and Gynecology
Thomas V. Whalen, MD – RRC Chair, Surgery
Where the Task Force has been
• International Duty Hours Symposium, ACGME
Annual Educational Conference, Dallas, TX,
March 2009
• ACGME Duty Hours Congress, Chicago, IL,
June 2009
• 11 meetings of TF, both face-to-face and virtual
Testimony Heard by TF Alone
• Expert Testimony in the following areas:
• History and impact of 2003 duty hours standards
• Report of ACGME Monitoring Committee on duty hours
• Sleep research & physiology
• Historical/political framework of IOM Report & duty hours
• Patient safety, quality, and the teaching hospital
• Effect of duty hours on Safety Net hospitals
• New York hospitals’ experience with duty hour regulations
• Duty hours and the legal perspective
• Fatigue management strategies
• Three (3) commissioned literature reviews
Commissioned Literature Reviews
• Conceptual frameworks in the study of duty hour changes in
graduate medical education: an integrative review
• University of Illinois at Chicago
• Systematic review of the literature: resident duty hours and
related topics
• Medical College of Wisconsin, Mayo Clinic College of Medicine,
Univ. of Chicago
• Systematic review of the literature on the impact of variation in
residents’ duty hour schedules on patient safety
• Jefferson Medical College
Testimony from the Profession
• Duty Hours Congress, June 2009 (two days)
• Testimony from over 65 groups representing the GME
community
• Need for flexibility: “one size doesn’t fit all”
• Reduction in medical errors is related to much more
than just duty hours
• Focus on all components of the learning
environment—not just hours
• Personal responsibility (professionalism) is essential
and must be fostered in fatigue management
• Patient safety is more than the alertness of the
resident taking care of patients at 3AM…senior
residents must be practice-ready
Further Concerns
• Work intensity/workload have greatest impact on
least experienced residents
• No evidence to support value of a maximum of
only four consecutive nights on night float
• Evidence from other vocations (airline pilots,
truck drivers) do not necessarily apply in MD
work environment
• Valid methods of detecting fitness for duty are
under development
• Concept of fatigue management is very
important
Fiscal Concerns
• IOM predicts $1.7 billion price tag
• ACGME concurs there will be a cost, but
study commissioned to determine amount
• Safety net hospitals are a major concern:
services must compete for available
dollars (medical care, education, public
services)
• Cost for additional regulatory oversight
(annual site visits to institutions)
• All are compounded by current recession
Keep in Mind….
• Patient safety, yes, but also….
• Resident well-being and
• Preparing the resident for independent
practice
We must remember that this is not just
about duty hours!!!
New Draft Requirements
Resident Duty Hours in the Learning and
Working Environment
(Currently posted on ACGME web site for comment)
Professionalism, Personal Responsibility, and
Patient Safety
• The program must be committed to and be
responsible for promoting patient safety
and resident well-being in a supportive
educational environment.
• The program director must ensure that the
residents are integrated into and actively
participate in interdisciplinary clinical
quality improvement and patient safety
programs
Professionalism, Personal Responsibility, and
Patient Safety
• The program director and institution must
ensure a culture of professionalism that
supports patient safety and personal
responsibility. Residents and faculty must
demonstrate:
• assurance of the safety and welfare of
patients entrusted to their care;
• provision of patient and family-centered care;
• assurance of their fitness for duty;
Professionalism, Personal Responsibility, and
Patient Safety
• management of their time before, during, and
after clinical assignments;
• recognition of impairment, including illness
and fatigue, in themselves and in their peers;
• attention to lifelong learning;
• monitoring their patient care performance
improvement indicators; and,
• honest and accurate reporting of duty hours,
patient outcomes, and clinical experience
data.
Transitions of Care
• Programs must design clinical
assignments to minimize the number of
transitions in patient care.
• Institutions and programs must ensure and
monitor effective, structured hand-over
processes to facilitate both continuity of
care and patient safety.
Transitions of Care
• Programs must ensure that residents are
competent in communicating with team
members in the hand-over process.
• Institutions must ensure the availability of
schedules that inform all members of the
health care team of faculty and residents
currently responsible for each patient’s
care.
Alertness Management
• The program must:
• educate all faculty and residents to recognize
the signs of fatigue and sleep deprivation;
• educate all faculty and residents in fatigue
mitigation processes; and,
• adopt fatigue mitigation processes to manage
the potential negative effects of fatigue on
patient care and learning, including naps and
back-up Call schedules.
Alertness Management
• Each program must have a process to
ensure continued patient care in the event
that a resident may be unable to perform
his/her patient care duties.
• The Sponsoring Institution must provide
adequate sleep facilities and/or safe
transportation options for residents who
may be too fatigued to safely return home.
Supervision of Residents
Introduction:
• Supervision may be exercised in a variety of methods.
Some activities require the physical presence of the
supervising faculty. The supervising physician for many
aspects of patient care may be a more advanced resident.
Other portions of care provided by the resident can be
adequately supervised by the immediate availability of the
supervising faculty or resident physician either in the
institution or by means of telephonic and/or electronic
modalities. In some circumstances, supervision may
include post hoc review of resident-delivered care with
feedback as to the appropriateness of that care.
Supervision of Residents
• In the clinical learning environment, each
patient must have an identifiable,
appropriately-credentialed and privileged
supervising faculty who is ultimately
responsible for that patient’s care.
• This information should be available to
residents, faculty, and patients.
• Residents and faculty should inform patients
of their roles in each patient’s care.
Supervision of Residents
• The program must demonstrate that the
appropriate level of supervision is in place
for all patients cared for by all residents.
Supervision of Residents
Levels of Supervision
• To ensure oversight of resident
supervision and graded authority and
responsibility, the program must use the
following classification of supervision:
• Direct Supervision – The supervising
physician is physically present with the
resident and patient.
Supervision of Residents
• Indirect Supervision:
• With direct supervision immediately
available – the supervising physician is
physically within the confines of the site of
patient care, and is immediately available to
provide Direct Supervision.
• With direct supervision available
– the supervising physician is not physically
present within the confines of the site of
patient care, but is immediately available via
phone, and is available to provide Direct
Supervision.
Supervision of Residents
• Oversight – The supervising physician is
available to provide review of
procedures/encounters with feedback provided
after care is delivered.
Supervision of Residents
• The privilege of progressive responsibility,
authority and a supervisory role in patient
care delegated to each resident must be
assigned by the program director and
faculty.
Supervision of Residents
• The program director must evaluate each
resident’s abilities based on specific
criteria. When available, evaluation should
be guided by specific national standardsbased criteria This refers to “MILESTONES”
• Faculty functioning as supervising
physicians should delegate portions of
care to residents, based on the needs of
the patient and the skills of the residents.
Supervision of Residents
• Senior residents or fellows should serve in
a supervisory role of junior residents in
recognition of their progress toward
independence, based on the needs of the
patient and the skills of the resident/fellow.
Supervision of Residents
• Programs must set guidelines for
circumstances and events in which
residents must communicate with
appropriate supervising faculty, e.g.,
transfer to an intensive care unit, end-oflife decisions.
Supervision of Residents
• The resident is responsible for knowing
the limits of his/her scope of authority, and
the circumstances under which they are
permitted to act with conditional
independence. In particular, during the
PGY1, residents must be supervised
either directly or indirectly, with direct
supervision immediately available.
This means that interns can never be in house without faculty
or more senior residents also in house supervising them
Supervision of Residents
• Faculty supervision assignments should
be of sufficient duration to assess the
knowledge and skills of the resident and
delegate to them the appropriate level of
patient care authority and responsibility.
Clinical Responsibilities
• The clinical responsibilities for each
resident must be based on the PGY-level,
patient safety, resident education, severity
and complexity of patient illness/condition
and available support services.
• (As further specified by the Review
Committee)
Note need for RRC to specify what these clinical responsibilities
are for residents at each level of training
Teamwork
• Residents must care for patients in an
environment that maximizes effective
communication. This must include the
opportunity to work as a member of
effective interdisciplinary teams that are
appropriate to the delivery of care in the
specialty.
Resident Duty Hours
• Maximum Hours of Work per Week
• Duty hours must be limited to 80 hours per
week, averaged over a four-week period,
inclusive of all in-house call activities and
moonlighting.
Resident Duty Hours
• Duty Hour Exceptions
• A Review Committee may grant exceptions
for up to 10% or a maximum of 88 hours to
individual programs based on a sound
educational rationale.
• In preparing a request for an exception the
program director must follow the duty hour
exception policy from the ACGME Manual on
Policies and Procedures.
Resident Duty Hours
• Moonlighting
• Time spent by residents in Internal and
External Moonlighting (as defined in the
ACGME Glossary) must be counted towards
the 80-hour Maximum Weekly Hour Limit.
• PGY1 residents are not permitted to
moonlight.
Inclusion of external moonlighting in 80 hours max is
a major change. This was an IOM recommendation.
Resident Duty Hours
• Mandatory Time Free of Duty
• Residents must be scheduled for a minimum
of one day free of duty every week (when
averaged over four weeks). At-home call
cannot be assigned on these free days.
NO CHANGE
Resident Duty Hours
• Maximum Duty Period Length
• Duty periods of PGY1 residents must not exceed 16
hours in duration.
• Duty periods of PGY2 residents and above may be
scheduled to a maximum of 24 hours of continuous
duty in the hospital. Programs must encourage
residents to use alertness management strategies in
the context of patient care responsibilities. Strategic
napping, especially after 16 hours of continuous duty
and between the hours of 10:00 p.m. and 8:00 a.m., is
strongly suggested.
Note absence of 5 hour nap
The PGY1 residents are expected to go home at the end of the 16 hr shift
Resident Duty Hours
• Maximum Duty Period Length
• It is essential for patient safety and resident
education that effective transitions in care
occur. Residents may be allowed to remain
on-site in order to accomplish these tasks;
however, this period of time must be no
longer than an additional four hours.
• Residents must not attend continuity clinics
after 24 hours of continuous in-house duty.
CHANGE FROM 6 HOURS TO 4 HOURS;
NO MORE CONTINUITY CLINICS
Resident Duty Hours
• Maximum Duty Period Length
• In unusual circumstances, residents, on their
own initiative, may remain beyond their
scheduled period of duty to continue to
provide care to a single patient. Justifications
for such extensions of duty are limited to
reasons of required continuity for a severely ill
or unstable patient, academic importance of
the events transpiring, or humanistic attention
to the needs of a patient or family.
Adds flexibility
Resident Duty Hours
• Maximum Duty Period Length
• Under those circumstances, the resident
must:
• appropriately hand over the care of all other
patients to the team responsible for their
continuing care; and,
• document the reasons for remaining to care for the
patient in question and submit that documentation
in every circumstance to the program director.
Resident Duty Hours
• Maximum Duty Period Length
• The program director must review each submission of
additional service, and track both individual resident
and program-wide episodes of additional duty.
But having flexibility has a price; will this be only occasional,
or become a real problem for PDs? Must be included in the 80
hours/week maximum.
Resident Duty Hours
• Minimum Time Off between Scheduled Duty
Periods
• PGY1 residents should have 10 hours, and must
have eight hours, free of duty between scheduled
duty periods.
• Intermediate-level residents [as defined by the
Review Committee] should have 10 hours free of
duty, and must have eight hours between scheduled
duty periods. They must have at least 14 hours free of
duty after 24 hours of in-house duty.
The RRCs will need to provide
specialty-specific definitions
Resident Duty Hours
• Minimum Time Off between Scheduled Duty
Periods
• Residents in the final years of education (as defined by the
Review Committee) should have eight hours between scheduled
duty periods. However, these residents must be prepared to
enter into the unsupervised practice of medicine and care for
patients over irregular or extended periods. Therefore, under
circumstances defined by the Review Committee and approved
by the ACGME, these residents may be permitted to return to
duty with fewer than eight hours between in-hospital activities.
This must occur only within the context of the 80 hour and one
day off in seven standards.
Again, more flexibility, this time for senior residents!
Resident Duty Hours
• Minimum Time Off between Scheduled Duty
Periods
• Circumstances of return to hospital activities
with fewer than eight hours away from the
hospital by residents in the final years of
training must be monitored by the program
director.
And again, the PD is on the hook to make sure this is all documented
Resident Duty Hours
• Maximum Frequency of In-House Night
Float
• Residents must not be scheduled for more
than six consecutive nights of night float.
• (The maximum number of consecutive weeks
of night float, and maximum number of
months of night float per year may be further
specified by the Review Committee)
RRCs may address this issue if they wish.
Limitation on night float is NEW…
Resident Duty Hours
• Maximum In-House On-Call Frequency
• PGY2 residents and above must be
scheduled for in-house call no more
frequently than every-third-night (no
averaging).
This is a change….averaging allowed before.
No more “every other night” in house call.
Upsetting to residents….precludes the “golden
week-end”
Resident Duty Hours
• At-Home Call
• Time spent in the hospital by residents on athome call must count towards the 80-hour
maximum weekly hour limit. The frequency of
at-home call is not subject to the every-thirdnight limitation.
• At-home call must not be so frequent or taxing
to preclude rest or reasonable personal time
for each resident.
Resident Duty Hours
• At-Home Call
• Residents are permitted to return to the
hospital while on at-home call to care for new
or established patients. Each episode of this
type of care, while it must be included in the
80-hour weekly maximum, will not initiate a
new “off-duty period.”
In other words, returning to the hospital while on At-Home Call
does not restart the “time off between scheduled
duty periods” clock
* as defined by the individual RRCs
Monitoring Compliance
• IOM has a negative view on the current ACGME
monitoring of compliance with duty hour
standards
• ACGME has beefed up monitoring and
sanctions in past couple of years
• New standards will be monitored by ANNUAL
visits to sponsoring institutions
• Beginning July 2011
• Results will be available to the public
• Cost may be around $12-15K/visit (rough estimate)
Next Steps
• Complete 45 day website posting
• ACGME Staff will collate all comments
• DHTF to meet late August to consider comments
and makes changes if and where indicated
• ACGME Committee on Requirements will
consider and hopefully approve at Sept. meeting
• Go to ACGME Board of Directors for final
approval at its Sept. meeting
• Go into effect July 1, 2011