Resident Times - Spring 2008

Welcome to the third issue of Resident Times - a semi-annual newsletter, providing the graduate medical education community with factual information pertinent to resident work hours and patient safety.

Print Newsletter
IN THIS ISSUE:

On The National Front

Meeting of the IOM Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules
By Veronica Wilbur, RN, MBA, CLNC, CHC

"Good morning, I cannot tell you how pleased I am to have such a body of experts coming together to find solutions to one of the preventable causes of errors in health

care-the extended shifts worked by graduate medical trainees in teaching hospitals and other health care..."

With these remarks, Carolyn M. Clancy, MD, Director of the Agency for Healthcare Research and Quality (AHRQ), opened the first meeting of the Institute of Medicine's (IOM) Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, held December 3, 2007 in Washington, DC.

AHRQ was charged by the House Committee on Energy and Commerce to conduct two major tasks with the broad goal of improving patient safety. The Committee will first examine current evidence of the relationship between resident work schedules and quality of care, and the strategies, tools, interventions and practices being deployed within and outside the United States to improve care and patient safety through optimization of resident work schedules. The Committee will then recommend short- and long-term strategies and the specific actions that need to be taken by all stakeholders to address this important issue. A final report is due in March 2009.

For the first meeting of the Committee, the IOM used a multiple panel format and opened presentations to the public. The first panel, represented by current and former members of the Accreditation Council for Graduate Medical Education (ACGME), discussed the organization's monitoring and enforcement of the Duty Hours Requirements, instituted in 2003.

The second panel, which included representatives from the American College of Physicians (ACP), American Medical Students Association (AMSA), and the past Chair of Resident and Fellows Section of the American Medical Association (AMA), spoke of the

"Impact of Duty Hour Requirements on Education" from several perspectives. Discussion included the potential for residents having car accidents following long shifts and the need for strong enforcement to change the medical culture.

The third panel, on "Work Hours, Patient Safety and Enforcement," included panel members from the Committee of Interns and Residents (CIR) and the Public Citizen Group, and Dr. Ethan D. Fried, Residency Program Director at St. Luke's-Roosevelt Hospital Center in New York, addressed the need for change. The New York experience was highlighted by CIR, including the use of monetary penalties for facilities that do not comply with NYS 405 regulations. Dr. Fried discussed the changes he has implemented within the St. Luke's-Roosevelt residency program to comply and the resulting costs and benefits.

The fourth panel discussed "Sleep and Outcomes Research." Panel members from Brigham and Women's Hospital, Partners Health Care, and Wharton School, University of Pennsylvania, focused on changes needed in the organization and management of resident

education programs.

The fifth and final panel, which included representatives from the Centers for Medicare & Medicaid Services (CMS) and Department of Veterans Affairs (VA) presented "The Federal Role Funding Graduate Medical Education." CMS' spokesperson presented

information on DME and IME payments and FTE caps, while the VA representative discussed the VA's initiatives regarding graduate medical education and external monitoring of timeliness.

Future information-gathering meetings are scheduled for May 8-9 and June 26-27, 2008. Both meetings will be held in Washington, DC. For additional information, visit http://www.iom.edu/CMS/3809/48553/48679/49628.aspx

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The New York State Experience

Tips for Preparing for the Annual IPRO Unannounced Survey
By Carrie Perfetti, JD

Each year hospitals sponsoring residency programs, as well as those serving as rotation sites for residents from other programs, undergo a survey conducted by IPRO pursuant to a contract with the New York State Department of Health, to determine their compliance with New York State regulations pertaining to resident working hours. While the unannounced nature of these surveys can be unnerving, following the tips below can provide some relief.

PREPARE

Whether your review is one month or one year away, the preparation

you do today can ease the burden of your annual review.

Keep the previous, current and next month's scheduling information accurate, up-to-date and readily available. Maintain a file or book with residents' scheduling information monthly so all schedules are ready and available the first day of the site review. If the program uses a sick, back up or jeopardy call system, make sure this is included with the scheduling information.

Collect call, conference and clinic schedules from the home institution sponsoring residents rotating into your facility. Even if your facility does not sponsor a residency program and just serves as a rotation site, these documents are going to be

requested from the home institution during a site review. Ease the burden of obtaining this information the day of an on-site review by collecting and maintaining it as a matter of routine.

Provide any codes/keys/explanations necessary to understanding rotation/call or clinic schedules. Any resources you can provide to the reviewers to aid in understanding schedules will prevent unnecessary interruptions to residents as well as Program

Coordinators.

Review all plans of corrections written in response to Statements of Deficiencies to ensure that the interventions listed have been implemented and that any monitoring activities are included in the plan. Give some thought to what documents, meeting minutes, policy revisions, etc., demonstrate implementation of your plan of correction. On a revisit, IPRO reviewers will collect and review documents

that substantiate the interventions/monitoring put into place.

Conduct and analyze periodic internal audits of your program. Review of your program's internal work hour monitoring and audits will help you prepare by alerting you to potential work hour issues. When speaking with an IPRO auditor tell them of any

issues identified on internal audits and interventions put in place to address and monitor.

SHARE

Sharing information with program staff and residents, as well as IPRO reviewers, is a second strategy that can ease the burden of the annual work hour audit.

Appoint a back up person to facilitate the IPRO review should it occur when the Program Coordinator/Director is on vacation or unavailable. The appointed back up personnel should know where all scheduling information is maintained and

how to access it. The back up person should also be able to provide an overview of how scheduling is done. In many facilities a Chief Resident is a good back up person because he/she is often involved in the scheduling process.

Share the facility's commitment to compliance with residents. While a schedule may be compliant, if residents are not adhering to the schedule as developed then you could have a problem. Let residents know they share in the responsibility to

ensure program compliance.

Share self-identified issues and actions/plans for improvement with IPRO. These activities are all things you are doing to achieve compliance with the work hour regulations; and you should get credit for your work. Additionally, if you have

identified these issues and are working on correction, chances are they will be identified on the work hour survey.

BE AWARE

Awareness of what is actually going on in your program related to work hours is the single most important action you can take to prepare for an IPRO audit. Below is a list of often overlooked issues that can sometimes lead to citation.

Know what time residents are coming into work in the morning. Just as important as the time residents leave, post call is the time they arrive. A call is scheduled from

7AM-7AM the next day and you know residents leave promptly at 10AM. If residents routinely come in at 5-5:30AM to prepare for rounds that start at 7AM, there will be a violation of the >24 hour plus three hours transition time provision of the work hour regulations. Be aware there is sometimes a difference between the time the residents' day officially starts per the schedule and the time they are actually starting in order to complete their work.

Know what time residents are actually leaving the hospital on short/long call days to ensure proper separation between shifts. While short/long call residents may be

responsible for covering admissions until 8PM, the time they leave the hospital may be well after that. While the policy/schedule is set up to have residents cover admissions to 8PM, residents may not actually finish with that admission until 11PM. If residents return to the hospital before 7AM. the next morning, they are in violation of not having eight hours separation between shifts. (Residents would

not be able to return until after 9AM to provide for a ten-hour separation for compliance with ACGME requirements.)

Review sick/back up/jeopardy call schedules to ensure residents on these schedules receive one 24-hour period completely free of any work related responsibility. Issues

with sick/jeopardy/back up call schedules are often overlooked and forgotten. The misconception from programs and residents alike is that if residents are on back up call and are not called into work, they have the day off. While literally true, technically that day residents on back up call are not completely free from all work responsibility as they need to remain within a specified distance to the hospital and available to work should the need arise. Issues with back up call systems are generally seen where residents are scheduled as back up coverage for a month at a time, for the duration of a rotation period, or for two weeks consecutively

without a break. In such cases, devise a system where the person designated for back up receives one full 24-hour period free from work or any potential obligations to the facility/program.

Know what kind of coverage residents are providing at the home institution if your site is a rotation site for residents from another institution. As the rotation site

you need to know what responsibility residents have to their home institution while at your facility. The hours worked providing cross coverage are calculated into the total work hours for residents. As a rotation site you need to know and account for these hours so residents are not further scheduled in a manner that violates work hour regulations.

While any unannounced survey by its nature can be stressful, if you prepare, share and are aware you can ease some of the burden at the time of the review.

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Graduate Medical Education: Past, Present, and Future

Articles of Interest
What Potentially Lies Ahead?
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Legal Watch

Work Hours on the Radar screen Nationally and at the State Level

While passage of ACGME guidelines addressing resident working hours in 2003 seemed to quiet discussion of federal legislation addressing the issue, the following recent developments at both the state and national levels prove that the issue is still topical.

The U.S. House of Representatives Committee on Energy and Commerce and its subcommittee on Oversight and Investigation launched an investigation into preventable medical errors. In a March 29, 2007 letter, the Committee requested that the Federal Agency for Healthcare Research and Quality conduct a study of medical errors associated with physician and resident work schedules.

In New Jersey, Assembly Bill A. 998 of the bills of 2006-2007 was introduced limiting resident work hours to 80 per week over a four-week period of time and 24 consecutive hours.

In Massachusetts, Senate Bill S. 1247 was referred to the Committee on Public Health on January 10, 2007. This bill defines as mistreatment working any duty hours in violation of those prescribed by the ACGME standard, or any limits defined by the Department of Public Health. It further states, "Duty hours by residents, interns and fellows in excess of the standard established for duty hours for resident-physicians by the ACGME for interns, residents and fellows; or such lower duty hour limits established by regulation by the department of public health, shall be prima facie evidence of mistreatment of patients for which said resident-physician is caring for." This seems to bring to the state level the issue of the ACGME standard having "teeth" through enforcement provisions.

In Pennsylvania, Senate Bill S. 1224 was referred to Public Health and Welfare as recently as December 21, 2007. This proposed bill has a provision similar to New York's with respect to work hour limits, limiting work hours to 80 in one week, 24 hours in a day, 24 hours off per week, and an eight hour separation between shifts.

While these bills have not yet been passed, they demonstrate that resident work hours and their impact on public safety continues to generate discussion.

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Upcoming Events

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Web Resources

Resident work hour news, discussions, and current projects can be further researched at the following Web sites:

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We Want to Hear from You!

Please email us at sruhland@ipro.org with stories about your experiences, ideas about topics you would like to see covered in future issues, and any questions you may have about our program.

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Resident Times is published twice yearly by the IPRO Hospital Compliance Department. Additional copies are available by calling 800-233-0360, extension 114.

Editors:

IPRO Regional Office: 20 Corporate Woods Boulevard, Albany, New York 12211-2370

IPRO Corporate Headquarters: 1979 Marcus Avenue, Lake Success, New York 11042

Resident Times is published by IPRO, an independent, not-for-profit corporation providing a full spectrum of health care assessment and improvement services to public- and private-sector clients.

Incorporated in 1983, IPRO has evolved into one of the largest and most experienced health care evaluation and quality improvement organizations in the nation. IPRO's professional staff includes more than 350 physicians,

registered nurses, epidemiologists, biostatisticians, data analysts, health policy experts, programmers, medical record personnel and systems analysts, as well as a network of more than 300 board-certified physician consultants.

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