The Accreditation Council for Graduate Medical Education (ACGME) task force charged with reassessing resident training program standards today presented a comprehensive set of draft standards that revise requirements for supervision and duty hours to better match residents' levels of experience and emerging competencies, advancing both graduate medical education and quality patient care in the nation's teaching hospitals.
Summarized in an article published in the June 23 online edition of the "New England Journal of Medicine," the draft standards build on the recommendations made by the Institute of Medicine (IOM) in 2008. While proposing that the recommended maximum weekly work hours stay the same as the ACGME's current standard of 80 hours per week averaged over four weeks - as per the IOM's recommendations - the draft standards do propose significant changes to resident training. The draft requirements would:
- specify more detailed directives for levels of supervision necessary for a first-year resident (known as a PGY-1) vs. more experienced residents;
- reduce duty periods of first-year residents to no more than 16 hours a day;
- set stricter requirements for duty hour exceptions.
"Patient safety and an excellent, humanistic learning environment are the ACGME's twin prime objectives. The more closely the task force examined these related issues, the clearer it became that they were influenced by much more than just duty hours," said Thomas Nasca, M.D., M.A.C.P., chief executive officer of ACGME and vice chair of the task force. "And we recognized that a 'one size fits all' set of standards didn't make sense."
The proposed standards also establish new categories of standards and set requirements for teamwork, clinical responsibilities, communication, professionalism, personal responsibility and transitions of care. Among the new requirements, the draft standards would:
- establish graduated requirements for minimum time off between scheduled duty periods;
- expand program and institutional requirements regarding handovers of patient care;
- set more specific requirements for alertness management and fatigue mitigation strategies designed to ensure both continuity of patient care and resident safety.
"Teamwork, communication, ensuring seamless transitions of care of a patient from one physician to another, and providing appropriate levels of supervision and independence to residents are some of the vitally important issues we addressed. We want first year residents to have the resources and supervision they need to learn and provide excellent patient care while also assuring that residents near the end of their training are prepared to leave the program and practice independently."
Assessing the Data on Fatigue and Medical Errors
Noting that there is limited scientific data on the connection between fatigue and medical errors for the resident community, Dr. Nasca pointed out that ACGME's revised draft standards reflect data showing that fatigue has an influence on the frequency of errors by first-year residents. "These are the least experienced and most vulnerable physicians in training, and the task force saw a need to make the most significant changes in the supervision and duty hour standards for this group," he observed.
As residents progress in their training, the task force also recognized its obligation to adequately prepare individuals to practice medicine outside the learning environment where they will be unsupervised, must think independently, and often must function at their top abilities when fatigued. "Nobody wants the only neurosurgeon in the county to be unable to provide excellent patient care when, after operating all day, he or she is called back to the hospital emergency room to relieve an accident victim's intracranial bleeding," Dr. Nasca said.
The task force also considered a variety of studies that indicated reducing duty hours does not necessarily reduce medical errors or enhance residents' average sleep time. Furthermore, independent longitudinal research has demonstrated that the 2003 standards have resulted in a significant decrease in the average number of hours that residents work per week. For the first time since the annual survey was initiated in 1977, that number of hours is less than 60 hours per week. (Staiger, DO, et.al. JAMA. 2010;303(8):747-753)
In addition, a comprehensive review of independent research on quality care issues demonstrated no connection between mortality and morbidity at hospitals and resident duty hours. The literature did, however, indicate "handovers" - transitioning a patient's care from one physician to another - can lead to medical errors because of the potential for miscommunication. Consequently, the draft training standards attempt to both limit resident fatigue and minimize the number of patient handovers by structuring duty hours so that transitions in care occur only twice a day.
"In revisiting resident training standards the task force considered many issues, not just duty hours, that can spark an emotional response," Dr. Nasca said. "Our process strove to strip away the emotion and evaluate the available scientific data to make the proposed new standards as evidence-based as possible."
Recommendations Based on 16-month Scientific Review
Honoring a commitment to study and revise the current resident duty hours standards, issued in 2003, after a cohort of residents had completed training under those requirements, ACGME began the process of reassessing its resident training requirements for all specialties in February 2009. That June it convened a special Task Force on Quality Care and Professionalism to draft proposed new standards.
The 16-member ACGME task force represents leading specialists in medical education, patient safety and clinical care including 12 physicians with extensive experience in graduate medical education programs, three residents and a public representative with extensive experience in evaluating health care related issues. The group's co-chairs are E. Stephen Amis, M.D., chair of the Council of Review Committees, a group made up of the chairs of the Residency Review Committees that review residency programs in the various specialties, and university chair of the Department of Radiology at Albert Einstein College of Medicine and Montefiore Medical Center in New York, and Susan H. Day, M.D., chair of the ACGME Board of Directors and chair of the Department of Ophthalmology at California Pacific Medical Center, San Francisco. A complete list of task force members can be found at www.acgme-newstandards.org.
Over the past year, the task force conducted a thorough examination of patient safety, duty hours, resident supervision, educational outcomes and training standards that included hearing testimony from more than 100 individuals, receiving written presentations from 100 medical organizations and commissioning three independent reviews of the literature on sleep issues, patient safety and resident training.
Dr. Nasca noted that the task force benefited from the dialogue begun by the Institute of Medicine (IOM) committee that drafted the report, "Resident Duty Hours: Enhancing Sleep, Supervision and Safety," which was released in December 2008. Four members of that committee made formal presentations to the task force and three of those members were invited back for more in-depth discussions. (A comparison of the 2003 standards with the IOM recommendations and new proposed standards is available at www.acgme-newstandards.org.
The proposed resident training standards have been posted on the ACGME website and will be available for public comment for 45 days. The task force will review the feedback and consider modifications to the draft standards. A final version will be presented to the Committee on Requirements of the ACGME Board and, if approved, presented to the entire board for approval in September 2010. They would then be implemented in July 2011. (A timeline of the development, review and approval process for the proposed standards is available at www.acgme-newstandards.org.)
Patient Safety and Quality Assurance Site Visits
Separately from the task force development of proposed standards, the ACGME Board has approved creation of a Patient Safety and Quality Assurance review of every sponsoring institution that would begin after implementation of the new standards. To ensure compliance, each year the ACGME will review every institution sponsoring graduate medical education programs, examining their ability to integrate residency education, supervision and fatigue management into their existing Patient Safety and Quality improvement initiatives. More
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