November 18, 2010

AnnouncementsACGME Annual Educational Conference

Nashville, March 3-6, 2011

Second Look Weekend – Physician ScientistsJanuary 20-22, 2011

Second Look Weekend – Underrepresented MinoritiesFebruary 3-5, 2011

EDP Workshop – “Communicating with Healthcare Team Colleagues in Ways that Promote Collaboration …”Dec 14, 2-4pm, PRB 898-KRSVP: medical.education@vanderbilt.edu

Rock Away the BlahsFebruary 19, 2011; Canner Ballroom - tentative

AgendaACGME Resident Survey

Monitoring CommitteeCommon Program Requirements

Duty HoursSupervisionTransitions in Care

Resident Survey ContentFive Main Areas

FacultyEducational Content EvaluationResourcesDuty Hours

RS: FacultyDo the (or your) faculty:

…spend sufficient time teaching?…spend sufficient time supervising?…regularly participate in organized clinical discussions?…regularly participate in rounds?…regularly participate in journal club?

RS: Educational ContentAccess to program’s written goals and objectivesAccess to written goals and objectives for each

rotation and major assignmentFatigue and sleep deprivation educationOpportunity for research or scholarly activityEmphasis of education over service obligation

RS: EvaluationOpportunity to evaluate faculty annuallyOpportunity to evaluate program annuallyReceive rotation or assignment feedbackAbility to review current and past evaluationsOpportunity to assess program for improvement

purposes

RS: Resources & Duty HoursDo non-program trainees interfere with your

education?Mechanisms available to raise and resolve issues

without fear of intimidation or retaliationHow often are you able to access needed specific

and reference materials?

Duty Hour QuestionsIncluding moonlighting counted

The Monitoring Committee Independent of RRCs but feeds information to them4 programs here affected in last 2 years5 levels

Category 1: The WorstDefinition:

Duty hour non-compliance in two consecutive years of the last three years or

Duty hour non-compliance in two of the last three years, and non-compliance in >=4 FS areas in last year, or

Duty hour non-compliance last year and non-compliance in >=4 FS areas last year, AND problems in >=2 FS areas over the last two years.

RRC Action: If not already scheduled, site visit in 6

months. (1 program here in last 2 years)

Category 2: The DistressedDefinition:1. Duty hour non-compliance in last year, and2. Non-compliance in >=4 FS areas in last year.

RRC Action: If not already scheduled, site visit in 6 months. (Note: RRC is allowed discretion with appropriate rationale to ACGME)

Category 3: The WarnedDefinition:1. Duty hour non-compliance in last year, and2. Non-compliance in 1 – 3 FS areas last year.

RRC Action: Letter from the RRC Executive Director and the IRC Executive Director cautioning programs and institutions. (2 programs here in last 2 years)

Category 4: The FenceDefinition:1. Duty hours compliant.2. Non-compliance in 2+ FS areas for past 2consecutive years, or3. Non-compliance in 4 FS areas last year.

RRC Action: If site visit >1 year, Committee will review the specific program and consider shortening the cycle or a cautionary letter from the RRC Executive Director. (1 program here in last 2 years)

Category 5: The WatchedDefinition:1. Duty hours compliant.2. Non-compliance in 2 or 3 FS areas last year.

RRC Action: Letter from the RRC Executive Director that “we are watching you.”

Questions?

http://acgme-2010standards.org/ Section VI – Resident Duty Hours in the Learning

and Working EnvironmentProfessionalism, Personal Responsibility, and Patient

SafetyTransitions of CareAlertness Management/Fatigue MitigationSupervision of ResidentsClinical ResponsibilitiesTeamworkResident Duty Hours

Task Force ProcessesExtensive Data-Gathering

National Duty Hour Congress, June 2009

10 meetings from 7/09-4/103 independent literature

reviews – GME, sleep issues, patient safety

Web-based survey – DIOs, PDs, faculty, residents

Position statements - >100 med orgs, 100 individuals; US, Canada, UK

4 members of IOM cmte

Expert testimony 2003 duty hours standards –

history and impact ACGME Monitoring Committee Sleep physiology, research IOM Report & duty hours –

historical/political framework Teaching hospital role – patient

safety, quality Safety net hospitals New York hospitals’ experience Legal perspective – duty hours Fatigue management/mitigation

strategies Public patient safety advocates

Objectives & Guiding PrinciplesPatients receive safe, quality care in the teaching

setting todayResidents provide safe, quality care in future

independent practiceClinical learning environment – humanistic,

professionalSelf-regulation of the professionCoherent standards – not simply duty hoursOne size doesn’t fit all – levels, competencies -

milestonesBready, AAMC-GRA 2010

Where are the changes?Introduction – statement of principles

Section VI – Resident Duty Hours in the Learning and Working Environment

New- Duty HoursUp to 80 h/wk, averaged over 4 wks

All moonlighting countsContinuous duty

PGY-1 residents – up to 16 hPGY-2 and up – up to 24 h (should nap) + 4 h for transition

of careUnusual circumstances past 28 - must be monitored,

individualIn house call frequency – up to q3, avg (unchanged)Minimum 1 day in 7 free, averaged (unchanged)Maximum 6 consecutive nights on night float

New- Duty Hours (con’t.)Minimum time off between duty periods

PGY-1 residents should have 10 hours and must have 8 hours free of duty between scheduled duty periods

Intermediate-level* residents should have 10 hours free of duty and must have 8 hours between scheduled duty periods Must have at least 14 hours free of duty after 24 hours of in-house

dutySenior level residents* should have 8 hours between

scheduled duty periods May return to duty with fewer than 8 hours – to be defined by RRC This early return to duty must be overseen by the program director

New – Supervision LevelsDirect Supervision - The supervising physician is

physically present with the resident and patient.Indirect Supervision

Direct supervision immediately available – The supervising physician is physically within the confines of the site of patient care and immediately available to provide Direct Supervision.

Direct supervision available – The supervising physician is not physically present within the confines of the site of patient care, is immediately available by phone, and is available to provide Direct Supervision.

Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

New – Supervision (cont.)Supervising physician

Faculty member or more senior residentDelegate portions of care to residents – needs of the patient, skills

of resident*Faculty - Sufficient duration to assess knowledge/skills

ProgramsGuidelines for residents to communicate with supervising facultyResident’s abilities based on specific criteria (“milestones”)*

PGY-1 residentsMay not be alone on a hospital service (either Direct Supervision or

Indirect with Direct Immediately Available)*details to come from RRCs

ExerciseIdeal SupervisionWhat are my program’s strengths?Where is this problematic for my program?

The Superb/Safety Modelhttp://www.jgme.org/doi/pdf/10.4300/JGME-D-09-00

015.1

New – Clinical ResponsibilitiesThe clinical responsibilities for each resident must

be based on:Patient safetyPGY-levelDemonstrated resident skills/knowledgeSeverity & complexity of patient illness/conditionAvailable support services

Optimal clinical workload specified by each RRC

New - TeamworkResidents must care for patients in an environment

that maximizes effective communication

This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty

Further defined by RRC

New – Professionalism, Personal Responsibility, Patient SafetyResidents must take personal responsibility for, and faculty

must model:Safety and welfare of patients;Patient and family centered care;Fitness for duty;Management of time before, during, and after clinical assignments;Recognition of impairment in self and peers;Attention to lifelong learning;Monitoring their patient care PI indicators;Honest and accurate reporting – duty hours, patient outcomes,

clinical experience data

New – Transitions of CareDesign clinical assignments to minimize the number of

transitions.Effective, structured handover processes to facility both

continuity of care and patient safety.Residents must be competent in communication with

team members in the handover process.Schedules that inform (patients and) all members of the

health care team of faculty and residents currently responsible for patient care.

Residents and attendings should inform patients of their role in the patient’s care.

New – Alertness ManagementAll faculty and residents

Recognize the signs of fatigue and sleep deprivationFatigue mitigation processesNaps, back-up call schedules

Process – continued care in the event that a resident may be unable to perform his/her patient care duties

Adequate sleep facilities and/or safe transportation options for residents who may be too fatigues to safely return home

Timeline & ComplianceCPRs become effective 7/1/2011Patient Safety and Quality Assurance review

approved by ACGME BoardEvery sponsoring institution – annual visit (beginning

2012) Integrate residency education, supervision, and fatigue

management standards into quality assurance initiatives Projected cost to institution: $12,000-$15,000/yr

Results of surveys would be available to the publicDetails pending