Accreditation Council for Graduate Medical Education Duty Hours

Accreditation Council for Graduate Medical Education Duty Hours Task Force Update June 20, 2010 Society of Neurological Surgeons

“I’m from the ACGME and I’m here to help you. ” The New Duty Hours Standards: It could have been much worse.

• Details of release of the New Standards • Make up of Task Force • Activities of the Task Force • General Discussion of the Result

Duty Hours: Recent Developments • Task Force has developed new standards • Standards to be released for public comment Wednesday, June 23 rd

Background • Public Citizen, SIEU/CIR, Sleep scientists in concerted action to influence ACGME and public opinion to adopt IOM recs in toto • Wakeupdoctor. org • ACGME is carefully managing communication to the public and all stakeholders • Non-disclosure agreements by Task Force

New Duty ACGME Hours Standards • Time Line for Release of the New ACGME Duty Hours Standards • June 23 rd – Wednesday - 5 PM • New Standards Published on Line • Article Published on line in the New England Journal of Medicine • 45 day Public Comment Period begins • Task Force Meets again to modify Standards

New Duty ACGME Hours Standards • September-Standards go to Committee on Program Requirements • September – approval by Board of ACGME • February – Board approves RRC input • Goes into effect: July 1, 2011 • Financial impact analysis

Perspectives on Committee • • • General Surgery (DIO) Vascular Surgery (DIO) Colon and Rectal Surgery(R) Neurosurgery Obstetrics and Gynecology Ophthalmology (CC) • Public Member CC- Co-Chair VC – Vice Chair DIO – Des, Inst. Off. • • • Pediatrics (+R) Family Medicine Emergency Medicine Radiology (CC) Internal Medicine: • Pulm/Critical Care (R) • Gastroenterology (DIO) • Nephrology (VC) • Anesthesiology (DIO) R- Resident Member +R – Resident in addition to RRC Chair

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, Internal 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

Task Force Activities • International Duty Hours Symposium, Annual Educational Conference, Dallas, TX, March 2009 • Duty Hours Congress, Chicago, IL, June 2009 • Ten meetings, both face-to-face and virtual, from July 2009 – April 2010

I. Review/Revision of Resident Duty Hour Standards Communication with the Community ü ü ü ü Web Based Survey of DIOs. Program Directors, Faculty, and Residents (Jan-April, 2009) Request for Organizational Positions (Feb-April 2009) International Symposium –March 4 -5, 2009 Annual ACGME Educational Meeting –March 6 -8, 2009 Task Force Formed Formal Review of the Literature (External- RFP’s filled three selected) National Congress on Duty Hour and the Learning Environment (June, 2009)

Task Force Activities • • • • Duty Hours Congress, June 2009 Testimony heard from over 65 groups from the GME community Expert Testimony in the following areas: History and impact of 2003 duty hours standards Report of Monitoring Committee on duty hours Sleep research and physiology Three commissioned literature reviews Historical/political framework of IOM Report and duty hours Patient safety, quality, and the teaching hospital Safety net hospitals NY hospitals’ experience Duty hours and the legal perspective Fatigue management strategies

ACGME TF vs. IOM • 17 members • 1 PD • 0 active surgeons • 6 clinicians • 2 active ACGME Task Force • 16 members • 13 PD’s • 3 active surgeons • 15 clinicians • 15 active

IOM Public Meetings December 3, 2007 Open Session 6. 5 Hours Surgery 15 min. March 4, 2008 Open Session 5. 5 Hours May 8 -9, 2008 Open Session 2 Hours =14 hrs.

Changing the Discussion • It is not just about duty hours • It is also about: • Patient safety • Appropriate levels of supervision • Professional responsibility of the residents to show up rested and fit for duty

Supervision • GME has been dominated by the “Internal Medicine” model – intern runs everything • Neurosurgeons, in general, have developed model systems for resident supervision and a defined hierarchy in their clinical services and training programs • Supervision enhancement will be a major part of the new standards

During the daytime to what degree are senior residents given graded responsibility and authority for patient care commensurate with their level of training? 80, 00% n=168 70, 00% 60, 00% 50, 00% 40, 00% 30, 00% 20, 00% 10, 00% 1 = Inadequate delegation of authority and responsibility 2 3 = Optimal delegation of authority and responsibility Internal Medicine and SS Pediatrics and SS, Fam Med and SS Hospital Based Specialties DIO's and GME Administrators 4 5 = Excessive delegation of authority and responsibility Surgery and Surgical SS

During the Night to what degree are senior residents given graded responsibility and authority for patient care commensurate with their level of training? 80, 00% n=169 70, 00% 60, 00% 50, 00% 40, 00% 30, 00% 20, 00% 10, 00% 1 = Inadequate delegation of authority and responsibility 2 3 = Optimal delegation of authority and responsibility Internal Medicine and SS Pediatrics and SS, Fam Med and SS Hospital Based Specialties DIO's and GME Administrators 4 5 = Excessive delegation of authority and responsibility Surgery and Surgical SS

Levels of Supervision Direct 1 2 3 4 Direct supervision by senior resident or above at all times; Chief/fellow and faculty member immediately available for OR cases (on campus). Chief/fellow and faculty member available by phone with ability to return to campus within 30 minutes for other patient care situations. Chief/fellow review (in person or by phone) within 12 hours. Direct supervision by chief resident or above except for most basic care; Direct faculty supervision at critical portions for OR cases; Faculty member immediately available for OR cases (on campus). Direct faculty supervision at critical portions. Direct supervision by senior resident or above at critical portions; Chief/fellow and faculty member immediately available for OR cases (on campus). Chief/fellow and faculty member available by phone with ability to return to campus within 30 minutes for other patient care situations. Chief/fellow review (in person or by phone) within 12 hours.

Levels of Supervision Indirect/Retrospective 5 6 7 8 9 Indirect supervision by senior resident, chief resident or fellow. Chief/fellow immediately available (on campus). Chief/fellow review (in person or by phone) within 4 hours. Indirect supervision by chief resident/fellow. Chief/fellow available by phone with ability to return to campus within 30 minutes. Chief/fellow review (in person or by phone) within 12 hours. Indirect supervision by faculty; Faculty member available by phone with ability to return to campus within 30 minutes. Faculty review (in person or by phone) within 18 hours. Retrospective supervision by chief/fellow; Chief/fellow reviews patient care within 24 hours. Retrospective supervision by faculty; Faculty member reviews patient care within 48 hours. http: //www. utmem. edu/GME/supervision. php http: //www. musc. edu/gmehandbook/policies/res_supervision_UNUSED. html

Neurosurgery Levels of Supervision 5 5 4 1 6 6 6 7 7 CHIEF (PGY 67) 7 7 5 6 6 6 7 7 1 2 6 6 7 9 5 6 6 8 9 9 1 4 1 1 1 5 6 6 2 2 2 6 6 6 4 3 3 6 7 7 7 3 3 9 9 7 9 3 3 9 6 6 8 8 9 9 PGY 1 PGY 2 PGY 3 PGY 4 PGY 5/6* New Admission Consults ER Trauma Continuing Care (including pre- & post-op) INPATIENT CARE Unit Patients Hospital Discharge/Transfer Bedside Procedures Call Critical Events OR Intra-op OUTPATIENT Clinic Procedures CARE Clinic Exam RADIOLOGY/ PATHOLOGY *Acting Chief (Research & Elective Years)

Professionalism • “Fatigue can not be eliminated in a 24/7 activity – fatigue must be managed” David Dinges Ph. D April 2010 • Part of the professional responsibility of the resident is to show up ready to work and fit for duty • Fatigue mitigation strategies including the strategic use of medications (e. g. caffeine) and napping must be used by PD’s and residents

The Continuum of Professional Development Authority and Decision Making versus Supervision High Physical Diagnosis Clerkship “Graded or Progressive Responsibility” Sub-Internship Supervision Internship Residency Low Fellowship Low Attending Authority and Decision Making Increase the Accreditation Emphasis on Educational Outcomes High

The Continuum of Professional Development Authority and Decision Making versus Supervision High Physical Diagnosis Clerkship Sub-Internship Supervision Residency Low “Graded or Progressive Responsibility” Fellowship FALLING OFF THE CLIFF INTO PRACTICE Attending Low Authority and Decision Making Increase the Accreditation Emphasis on Educational Outcomes High

Recognition of the Senior Resident role • Semi-continuous responsibility “for the service” over irregular periods of time • Can a chief resident come back to the hospital to do a critical operation without initiating a new “minimum time off between duty periods” • Senior residents must be prepared to enter the autonomous practice of medicine

Enforcement of Resident Duty Hour Standards Enhancing Accountability • Two tiered assessment of compliance • Programmatic compliance • • As currently judged by each Review Committee, overseen by the Monitoring Committee Institutional environment, oversight, supervision, engagement of programs and residents in Patient Safety and Quality Improvement processes • • Yearly Site Visits, ± Unannounced Site Visits CEO of Sponsor and Participating Site Signatory Grading of Compliance (not binary) Publication of Results on ACGME website

Fiscal Concerns • IOM predicts $1. 7 B price tag • IOM and ACGME both agree there will be a cost and a responsibility to pay • Safety net hospitals/ concern re: competing goods (education, public services) • Cost for additional regulatory oversight (may need annual site visits to institutions) • Compounded by current recession

Key Elements Identified • “One Size Does Not Fit All” • Supervision • Graded Authority and Responsibility • Hand-Overs, Continuity of Care from the Patient’s Standpoint • Resident, Residency, GME “Enterprise” Engagement in Patient Safety and Quality Improvement Programs • Range of Sensitivity to Fatigue • Impact on Professional Development and Honor

The Importance of Neurosurgery Input During Public Comment Period • The other side will certainly be providing criticism of the new standards • Neurosurgeons must weigh in with specific suggestions to improve the new standards • BE CRITICAL and Them What You Think and Why!!!!