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9 Resources to Implement Improvements for Patient Safety and Resident Training
Pages 295-328

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From page 295...
... committee found the issues of patient safety, resident safety, duty hours, and schedules closely related to broader issues of how graduate medical education is structured, including the work environment, the supervision of residents, and safety practices throughout the training institutions. While recommendations on a particular topic are embedded in the scientific evidence of its corresponding chapter and presented serially in this report, the committee intends the report and all of its recommendations to be considered as a whole.
From page 296...
... Without the necessary restructuring in resource allocation, attempts to implement the recommendations will fail to have the desired benefits and could even reduce patient safety. The committee believes that the Accreditation Council for Graduate Medical Education and the other organizations charged to implement aspects of the recommendations should begin their work with urgency, and that action on all recommendations should be taken within 24 months.
From page 297...
... Rather, it chose to create better opportunities for fatigue prevention and mitigation within the basic duty hour structure and to focus on supervision, handovers, and other systemic changes to enhance learning and safety. The intent in adjusting the 2003 Accreditation Council for Graduate Medical Education (ACGME)
From page 298...
... The chapter concludes with a phased implementation strategy and addresses the necessity of further research, data collection, and evaluation that would allow consideration of the appropriateness of resident duty hours in the future. COST IMPLICATIONS OF CHANGES TO DUTY HOURS Implementing workload reductions and adjustments to the 2003 duty hour limits will require replacing residents' time with that of other workers and entails substantial costs for society but also potential benefits to patient and resident safety.
From page 299...
... NOTE: CMS = Centers for Medicare and Medicaid Services; DGME = Direct graduate medical education payment; GME = Graduate Medical Education; HRSA = Health Resources and Services Administration; IME = Indirect medical education payment; NA = Not available; VA = U.S. Department of Veterans Affairs.
From page 300...
... For most hospitals, except the category of safety net teaching hospitals, the negative patient revenue margin is smaller than the positive total income margin. Safety net teaching hospitals, however, have a substantial negative patient revenue margin (–9.6 percent)
From page 301...
... landscape – 8 .0 Figure 9-1.eps –10.0 – 9.6 % –12.0 N o n - S a fe t y - N e t Secondar y S a fe t y- N e t N o n - S a fe t y - N e t Secondar y S a fe t y- N e t S a fe t y - N e t S a f e t y- N e t N o n -t e a c h i n g H o s p i t a l s Teaching Hospitals Type of Hospital FIGURE 9-1 Median margins of hospitals by teaching status. SOURCE: Andrews et al., 2007.
From page 302...
... . The committee is concerned that some safety net teaching hospitals may not have the resources under current funding mechanisms to provide the additional supports necessary to allow residents recommended opportunities to rest, transfer noneducational tasks to others, or offer residents sufficient supervision because their resources already are spread too thinly (Werner et al., 2008)
From page 303...
... : nursing aides, 229; laboratory technicians, 45; licensed vocational nurses, 320; midlevel providers, such as physicians assistants and nurse practitioners, 5,984; and attending physicians, 5,001. Given that there are 1,206 teaching hospitals across the country, less than one FTE would be needed on average per hospital for several of these provider types.
From page 304...
... , which could possibly produce lower cost estimates. Estimating Baseline of Resident Duty Hours, Rate of Violation, and Workload To estimate the direct annual costs of the proposed reforms, the difference between what residents work at baseline and what they would work under the proposed changes is calculated and called "excess resident work" hours.
From page 305...
... PGY-1 residents are more likely to violate duty hour limits than more senior residents or fellows because PGY-1s tend to have more inpatient months, more frequent extended duty periods, and more direct patient care responsibilities. Reducing the workload of only first-year residents is factored into the cost model, but the committee recognizes that it may become necessary in some or all of the specialties for workload to be reduced in other years of residency as well.
From page 306...
... This transfer could be accomplished at relatively modest cost compared to hiring other physicians to do residents' work. Substantial reductions in resident duty hours and workload, such as those represented by the cumulative total of the four proposed reform components, would probably not be achievable using midlevel providers alone.
From page 307...
... Costs of Replacing "Excess Resident Duty" Hours Table 9-3 shows the results of calculations for the four reform scenarios using other personnel as substitutes for the "excess resident work" hours. The cost projections are presented for two groups of teaching hospitals: all hospitals with ACGME-accredited programs (1,206 hospitals)
From page 308...
... Optional: Reduce maximum shift to 16 h   30.6% of 64,497 specialty residents above PGY-1 $192,950,559   30.6% of 15,610 subspecialty residents $56,812,524    Subtotal $249,763,084 Total, components 1-3 $1,326,064,134 Total, components 1-4 $1,575,827,218 NOTE: Totals may reflect rounding. aIncluding COTH hospitals.
From page 309...
... The cost estimates of the model do not include any assumptions of savings from work and education redesigns. Many institutions may find ways to streamline the work and training of residents to eliminate excess hours without having to hire substitutes for each and every resident hour reduced and without burdening existing residents with increased workloads.
From page 310...
... aMedicare indirect graduate medical education payment.
From page 311...
... • The frequency of extended duty periods during inpatient rotations for PGY-1s and all other residents, which affects the number of hours that would have to be replaced to accommodate the required sleep period for duty periods lasting from 21 to 30 hours, impacts the costs of Component 2. • The use of various healthcare professionals as task-tailored substi tutes, such as laboratory technicians and licensed vocational nurses; midlevel professionals, such as registered nurses and physician as sistants; and attending physicians or other residents affects the cost of covering the excess hours of residents and influences the costs of all four components, based on their assumed substitution patterns.
From page 312...
...  2 Vary assumption about noncompliance 0-100% of PGY-2+ specialty and of residents above PGY-1 with 80-hour subspecialty residents worked the hours workweek reported for PGY-1s in Landrigan (2006)  3 Vary assumption about call frequency Every third night to every seventh night during inpatient months for PGY-1  4 Vary assumption about call frequency Every third night to every seventh night during inpatient months for all residents above PGY-1  5 Vary assumption about frequency of PGY-2+ have 50 to 100% of rotations as inpatient rotations among residents PGY-1 in Landrigan (2006)
From page 313...
... Assuming at least some compliance with the proposed reforms (as illustrated with components 2, 3, and 4 of the model) , the lowest-cost estimate for implementing the potential reforms is $1.14 billion, while the highest is $2.52 billion.
From page 314...
... Since most PAE costs occur after hospital discharge, teaching hospitals are not very likely to experience direct and sizable cost offsets if the proposed duty hour reforms succeed in reducing PAEs.
From page 315...
... The costs of adapting to resident duty hours in 2003 were borne by teaching institutions under existing funding. Some institutions may have to make relatively few changes to comply with the committee's recommendations; they may have residency programs that do not schedule extended
From page 316...
... Hospitals Hospital Admission U.S. Hospitals Hospital Admission Hospital perspective –30% –$633,547,948 –$525,330 –$36.03 $130,424,709 $355,381 $15.58 –15% $471,139,635 $390,663 $26.79 $656,147,561 $1,787,868 $78.40 0% $1,575,827,218 $1,306,656 $89.61 $1,181,870,414 $3,220,355 $141.22 +15% $2,680,514,801 $2,222,649 $152.43 $1,707,593,266 $4,652,843 $204.04 +30% $3,785,202,384 $3,138,642 $215.25 $2,233,316,118 $6,085,330 $266.86 Societal perspective –30% –$4,995,355,121 –$4,142,086 –$284.06 –$1,945,367,346 –$5,300,728 –$232.45 –15% –$1,709,763,951 –$1,417,715 –$97.23 –$381,748,466 –$1,040,187 –$45.62 0% $1,575,827,218 $1,306,656 $89.61 $1,181,870,414 $3,220,355 $141.22 +15% $4,861,418,388 $4,031,027 $276.45 $2,745,489,293 $7,480,897 $328.06 +30% $8,147,009,557 $6,755,398 $463.29 $4,309,108,173 $11,741,439 $514.90
From page 317...
... The committee believes that additional funding and personnel should be made available to support workload reduction and compliance with the recommended duty hour limits so that they do not have undesirable effects on patient or resident safety. Residents experienced work compressed into fewer hours after the 2003 duty hour rules and now would have increased pressures.
From page 318...
... Recommendation 9-1: All financial stakeholders in graduate medical education, such as the Centers for Medicare and Medicaid Services, De partment of Veterans Affairs, Department of Defense, Health Resources and Services Administration, states and local governments, private insurers, and sponsoring institutions, should financially support the changes necessitated by the committee's recommendations to promote patient safety and resident safety and education, with special attention to safety net hospitals. • An independent convening body should bring together all the major funders of graduate medical education to examine current financing methodologies and develop a coordinated approach to generate needed resources.
From page 319...
... . The Council on Graduate Medical Education (COGME)
From page 320...
... Individual institutions may or may not find additional residents to be the preferred approach. A phased implementation of duty hours, its evaluation, and further research Phase-in of Recommendations To promote safe medical care, improve the education of doctors in training, and increase the safety of residents and the general public, the committee offers its recommendations, which should be implemented with all deliberate speed.
From page 321...
... The recommended periods for rest during extended duty and periods away from the hospital to allow for rest and sleep recovery are intended to establish safer working conditions, to protect residents from excessive fatigue, and to protect patients from fatigue-induced errors. The recommended duty hour parameters are also closely linked to the recommendations concerning workload, supervision, and funding.
From page 322...
... While the committee certainly does not want to increase workload or hours for residents, some programs might try to meet the recommended parameters of rest and work periods by increasing the frequency of overnight duty periods and reducing the current amount of time off duty. When Residency Review Committees (RRCs)
From page 323...
... Research could investigate whether duty hours can be further reduced from current recommendations. • Resident workload and its impact on patient safety.
From page 324...
... For example, grounds for ACGME's granting exceptions might have to be tightened or expanded; or further measures might be necessary after workloads are reduced through the elimination of noneducational activities, if the work remaining is consistently of too high an intensity. Additionally, such information, as previously mentioned, could also help to avoid major problems or unintended consequences, such as an aspect of the duty hour parameters producing insurmountable challenges to certain specialties more than others that cannot be handled on an exceptions basis; or residents not sleeping during the prescribed 5-hour rest period who may choose to catch up on paperwork instead of mitigating their fatigue; or some small residency programs having to close because of insufficient staff to cover the excess hours of residents.
From page 325...
... Because so many individuals and organizations have strong economic and professional interests in GME, and resident duty hours in particular, it will be a challenge to come up with an agenda for research projects. It will be even more challenging to design research projects that can produce sound scientific evidence of use to policy makers.
From page 326...
... Hours and Work Schedules to Improve Patient Safety, December 3, 2007, Washington, DC. COGME (Council on Graduate Medical Education)
From page 327...
... 2008. The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety: A study of resident experiences and perceptions before and after hours reductions.
From page 328...
... . Alternative ways of financ ing graduate medical education.


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