Resident Times Newsletter - Spring 2007

IN THIS ISSUE:

Welcome to the first issue of Resident Times
The New York Experience
GRADUATE MEDICAL EDUCATION - Past, Present and Future
Hospital Not liable for Sleep-Deprived Intern's Motor Vehicle Crash
Professional Liability Issues in Graduate Medical Education
WEB RESOURCE
DID YOU KNOW?-The IPRO Hospital Compliance Team
We Want to Hear from You!

Welcome to the first issue of Resident Times

Resident Times is a semi-annual newsletter intended to provide the graduate medical education community with factual information pertinent to resident work hours and patient safety.

You can look forward to reading about:

meeting residency education requirements without compromising patient safety
reporting of medical errors and near-miss incidents
changes in laws impacting residency hours compliance
upcoming events of interest to residency program directors
updates on the New York State experience
Web and print resources
and more.

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The New York Experience

New York's 121 teaching hospitals provide training to an estimated 25% of all post-graduate physicians in the country.

In 2001, IPRO began working under contract with the State of New York to monitor the compliance of the state's teaching hospitals with resident work hour regulations. Since then, with IPRO's external monitoring activities in place, resident work hour regulation violations in New York State have decreased.

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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GRADUATE MEDICAL EDUCATION - Past, Present and Future

1984

Resident work hours receive public attention as a result of the Libby Zion case in New York City.

1987

New York State forms the Bell Commission to establish work hour regulations for medical training programs, and becomes the only state with regulations mandating work hour limits on residents.

1998

Surprise inspections of 12 New York hospitals find them in violation of the Bell Regulations.

1999

A New York State Cardiology Fellow dies in automobile accident following a night on call, bringing physician work hours into the public eye once more.

2000

The Bell Regulations are strengthened when the New York State Legislature passes the Health Care Reform Act of 2000. Under the Act, all New York teaching hospitals will be monitored for compliance each year.

2001

Petition to the Occupational Safety and Health Administration requesting that limits be placed on hours worked by medical residents (HRG Publication #1570). Rep. John Conyers (D-MI) introduces the Patient and Physician Safety Protection Act of 2001 (H.R. 3236).

2002

Legislatures in New Jersey and Massachusetts introduce bills to reduce resident work hours.

2003

The Puerto Rico legislature passes Law #47 of 2003, which limits the work hours of resident physicians to 80 per week. Delaware and Pennsylvania legislatures introduce bills to reduce resident work hours. The Accreditation Council for Graduate Medical Education (ACGME) guidelines on resident work hours become effective.

2004

The New England Journal of Medicine releases Brigham and Women's Hospital studies linking resident's long hours to an increase in medical errors and increased risk to patient safety. The World Health Organization launches the World Alliance for Patient Safety (http://www.who.int/media centre/news/release) (last viewed on November 1, 2004).

2005

The New England Journal of Medicine releases a Harvard study linking resident working hours to an increase in automobile accidents. Rep. John Conyers (D-MI) introduces the Patient and Physician Safety and Protection Act of 2005 (H.R. 1228) - similar to H.R. 3236 of 2001. Report released disputing the positive effects of resident work hour limits and patient safety.

2005-2006 Legislative Session

Massachusetts Sen. Richard Moore promotes legislation regarding Resident work hours, Senate Bill No. 1263, An Act for an Investigation and Study to Develop Proper Work Rules for Resident Physicians and Interns, and it stalls. The Senate adopts its own version (Section 44 of Senate Bill No. 2822) of the state's health care reform legislation. However, it fails to gain agreement from House and is dropped from the final version. Another version (Senate Bill No. 1263), calling for a study of sleep deprivation among residents and interns, is still pending in the Massachusetts Senate Committee on Ways and Means.

2006

JCAHO announces 2007 Patient Safety Goals regarding effectiveness of communication between caregivers and implements a standard approach to "hand-off communications." Many argue that Resident work hours should not be reduced due to increased hand-offs occurring. Two Harvard Medical School studies released. One finds nationwide non- compliance in the first year following implementation of work-hour limits for Medical Interns. The other finds extended work shifts put Medical Interns at risk nationwide. JCAHO releases draft of 2008 Patient Safety Goals for review and comment. The draft includes a new goal to "prevent patient harm associated with health care worker fatigue." Brigham and Women's Hospital issues press releases stating that Doctors' extended-duration work shifts are associated with medical errors and adverse events and that a Brigham and Women's Hospital study found that extended work hours are associated with increased risk of medical errors and even patient death among first- year Residents.

What Potentially Lies Ahead?

release of more work hour studies
more states requiring public reporting of medical errors and near-miss incidents -greater public awareness of the connection between resident work hours, medical errors and patient safety risks
an increase in medical liability laws

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Hospital Not liable for Sleep-Deprived Intern's Motor Vehicle Crash

ED Legal Letter, November 1, 2006,(in www.nexis.com)

In the case of Brewster v Rush-Presbyterian, the Appellate Court of Illinois had to decide whether a hospital owes a duty to a person injured by an off-duty intern suffering from sleep deprivation due to the hospital's policy on working hours. The court cited four factors relevant to deciding whether public policy should impose a duty of care on the hospital:

the reasonable foreseeability of injury;

the likelihood of injury;

the burden of guarding against injury; and

the consequences of placing that burden on the hospital.

The court stated that the general common law rule established in a long line of Illinois Supreme Court cases was that there is no liability imputed to health care providers for injuries to third parties who are not patients in the hospital. The hospital would only be liable if a sleep deprived intern hurt one of the hospital patients. The Appellate Court noted it was not a legislative body and thus it was duty bound to follow the precedents declared by the state's highest court.

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Professional Liability Issues in Graduate Medical Education

Kachalia and Studdert; JAMA 2004; 292:1051-1056

This article highlights aspects of professional liability pertinent to GME Settings. Among the major points:

Resident physicians are generally held to the same standard of care as attending physicians in their respective specialties. Attending physicians face malpractice exposure not only for the care they provide but for the care they direct. They may be held vicariously liable for negligence of resident physicians working with them, or directly liable for inadequate supervision.

The publics attention to patient safety will continue to move the courts toward higher standards of supervision. Health care institutions and programs will bear legal responsibility for both the care they deliver and the negligence of employees, including failing to administer safe systems of care.

The most palpable aspect of the law affecting the day-to-day work of most resident physicians and clinical educators continues to be the risk of being sued.

The ACGME requires accredited institutions to sponsor training programs and to provide resident physicians with professional liability insurance for claims arising within the scope and duration of training.

The ACGME work hour restrictions present an interesting example of how such liability may be imposed in the case of resident physician error. An error occurring during a shift that violates the ACGME weekly hour limit may trigger a case against the program or sponsoring institution. A plaintiff could be expected to argue that the institution agreed to the work hour restrictions as a condition of ACGME accreditation and then violated this agreement, which led to resident fatigue and, ultimately, the error. Courts have previously taken this view of institutions that fail to follow their own GME rules.

The emphasis on systems approaches to patient safety can be expected to increase scrutiny of the administrative structures through which resident physicians deliver care. For full text, see http://jama.amaassn.org/cgi/content/full/292/9/1051

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WEB RESOURCE

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

www.amsa.org Information regarding campaigns, and legislative lobbying being done by the American Medical Student Association.

www.acgme ACGME Resident Work Hour Reports and useful links for Residents and Program Directors.

www.hourswatch.org A Web site sponsored by the Committee of Interns and Residents, and the American Medical Student Association, who together monitor and lobby for work hour enforcement.

sleep.med.harvard.edu Harvard Medical Sleep Study department with information regarding resident work hours and fatigue.

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DID YOU KNOW?-The IPRO Hospital Compliance Team

The IPRO Hospital Compliance Team is led by Veronica Wilbur, BSN, MBA, CLNC. Ms. Wilbur's extensive background in health care includes twenty years on staff in clinical and management positions at several New York hospitals. Under her direction, the IPRO Hospital Compliance Team has conducted over 500 facility-specific resident work hour reviews in New York State, consisting of over 25,000 resident interviews and record review, and conducted compliance assessments at two nationally recognized teaching facilities outside of New York State. Skilled health care professionals with expertise in clinical nursing, management and administration round out the team. They perform on-site pre-ACGME review survey audits; review policies, procedures and schedules; make recommendations for meeting compliance objectives; and offer educational seminars and training to incoming and current residents, program directors and medical staff.

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We Want to Hear from You!

Please e-mail 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. If you would prefer to receive this newsletter via e-mail, visit www.ipro.org/subscribe-ipro-rt

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

Editors:

Ethelind Ade, RN, BSN, JD

Assistant Director, Hospital Compliance

eade@ipro.org

800-852-3685, extension 430

Sheryl Ruhland

Administrative Coordinator, Hospital Compliance

sruhland@ipro.org

800-233-0360, extension 114

IPRO Regional Office: IPRO Corporate Headquarters:

20 Corporate Woods Boulevard

Albany, New York 12211-2370