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2 Current Duty Hours and Monitoring Adherence
Pages 47-88

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From page 47...
... As a result, residents remain susceptible to acute and chronic sleep deprivation, despite the intent of the 2003 duty hour limits to prevent fatigue. The commit tee found the need to enhance monitoring of and adherence to duty hour rules.
From page 48...
... duty hour limits are optimal for resident safety, patient safety, and education. Before determining this, it was important to understand how the current limits came to be, whether implementation of any of the limits has been problematic, how the limits have been monitored, and whether data on adherence to these limits are reliable.
From page 49...
... dies in a New York teaching hospital, her father claiming she died due to poor care delivered by overworked, fatigued, and inadequately supervised residents 1986 Responding to Zion's death, a grand jury recommends patient care improvements including limits on resident duty hours in New York State 1987 The Bell Commission recommends specific limits on resident duty hours and increased supervision of their work 1989 New York State sets duty hour requirementsa 1989-1990 ACGME sets an 80-hour limit in several specialties (internal medicine, dermatology, ophthalmology, and preventive medicine) and limits in-house call to every third night with 1 day off in 7 in all specialties, on average 1998 Surprise inspections in 12 New York hospitals find extensive violations of New York duty hour limits 2001 Public Citizen, Committee of Interns and Residents of the SEIU, and American Medical Student Association petition OSHA; Representative Conyers introduces the Patient and Physician Safety and Protection Act of 2001 (not enacted)
From page 50...
... In 1989, as a result of the recommendations, New York State implemented rules limiting total resident duty hours per week and the length of extended duty periods, as well as providing for time off from work to address resident fatigue (Table 2-2) . Table 2-2 compares New York State rules with subsequent proposals (Public Citizen petition and legislative proposals)
From page 51...
... . These duty hour limits apply to trainees in their fellowship years as well.
From page 52...
... a SOURCES:  New York State Laws and Regulations: Title 10 NYCRR, § 405.4 (1998)
From page 53...
... Every third night, Every third night, with Every third night, no averaging averaging no averaging 10 hours 10 hours 10 hours 24 hours off per 24 hours off per week, averaged 24 hours off per week, one full week, no averaging over 4 weeks weekend off per month; no averaging 12-hour shift limit, at least 12 hours an equivalent period of time off between shifts; 60-hour workweek with additional 12 hours for education Yes Some confidentiality protection Yes in complaint procedure Civil penalties Potential loss of accreditation; Civil penalties, not to exceed sufficiently large plan of correction $100,000 per training to deter violations; program in a hospital, with unannounced corrective action plans to the inspections Secretary of Health and Human Services; public disclosure on a hospital and residency training program-specific basis No No Yes, to cover hospital incremental costs to comply with regulations
From page 54...
... Other definitions of terms are available in a glossary in Appendix D Suggested Refinements to Duty Hours The committee heard testimony from organizations representing the graduate medical education community, which favored continuation of the current rules over any further reductions in duty hours (AAMC, 2008; ABNS, 2008; ACGME, 2007b, 2008c; ACS, 2008; AMA Resident/Fellow Section, 2007)
From page 55...
... . ADAPTING TO 2003 DUTY HOURs Have duty hours changed in response to 2003 duty hour limits?
From page 56...
... In a subsequent analysis of the change of pediatric residents' extended duty hours in three institutions, Landrigan et al.
From page 57...
... All 124 New York teaching hospitals have monitoring by both IPRO and ACGME. Substantial Compliance Versus Counting Each Violation ACGME and IPRO both use what they term a "substantial compliance model" for monitoring duty hours.
From page 58...
... Their reported rates are not directly comparable because ACGME reports violations by specialty program and by residents while IPRO reports by facility. In academic year 2006-2007, 8.8 percent of the residency programs reviewed by ACGME received one or more citations for a violation of "any rule" related to duty hour limits (Table 2-4A)
From page 59...
... 10.5   ACGME (any resident) 25.0 aIPRO percentages in this column represent values for the first 2 years of its contract with New York State.
From page 60...
... . IPRO reports that it seldom finds excessive violations of the 80-hour rule any more in New York, although some flexibility is factored into its monitoring as noted earlier. Similarly, ACGME data show few program or resident violations of the 80-hour limit when the substantial compliance threshold of 15 percent is applied.
From page 61...
... . The elements of the 2003 duty hour limits that provide opportunities for recovery from fatigue (days off per week, separation between shifts, limiting frequency of call)
From page 62...
... These observations raise questions about whether the same limits should apply across all specialties or years of training. Compliance Across Specialties Before implementation of the 2003 duty hour limits, there was great variability in total hours worked by different specialties, but even when mean duty hours were less than 80, on average, for a given specialty, a large percentage of its residents would still have been in violation of that limit at some point in the year (with the exception of those in pathology, dermatology, psychiatry, and preventive medicine)
From page 63...
... reported that programs with interns in internal medicine, pediatric programs, emergency medicine, and even psychiatry were equally likely to violate some duty hour rule as surgical programs for at least 1 month in the year. In New York, IPRO has found that internal medicine and surgery programs are almost equally noncompliant with the 24 + 3 hour extended duty period and the day off per week, at rates three or more times greater than the other specialties (Table 2-5)
From page 64...
... . Underreporting of Violations by Residents Residency programs monitor resident duty hours in a variety of ways, including by self-report on time sheets, telephone or computer log-in/logouts in the hospital, badge readers at entries and exits of hospitals or parking garages, and personal monitoring by program directors to ensure that residents are not still on the floor outside of duty hour limits (Asad et al., 2006; Chao and Wallack, 2004; Goldstein et al., 2005; Landrigan et al., 2008)
From page 65...
... . A survey of internal medicine, pediatric, and general surgical residents at one major teaching center found that 85 percent exceeded duty hour limits at least once in the previous 3 months and 48 percent admitted underreporting their hours (Carpenter et al., 2006)
From page 66...
... 32 h of flying 9+ h of scheduled time in any 7 flight timec consecutive daysb Shipboard 84 h per week 15 h per every 24 None None personnel on h and 36 h per tankersd 72 h Railroad None 12 h 10 consecutive None Federal Currently hours are conductorse,f hours after a Railroad recorded by hand; 4 12 h shift and 8 Administration major railroads have consecutive hours (FRA) upgraded to electronic during the 24 h recordkeeping prior to any shift Long-haul 60 or 70 h duty 14 h on duty with 10 consecutive 34 h Federal Motor Drivers are required truck driversg time per 7- or 8- a maximum of 11 hours, drivers continuous rest Carrier Safety to record a log of day shift h spent driving with sleeper period prior to Administration hours for each 24 h berth must spend any 7- or 8-day (FMCSA)
From page 67...
... fFederal Railroad Administration, 2008. gFederal Motor Carrier Safety Administration.
From page 68...
... . Paperwork is frequently done in all transportation modes outside duty hour limits.
From page 69...
... MONITORING DUTY HOURS The level of adherence to resident duty hour limits has raised questions about the current approach to monitoring duty hours and whether the culture of expectation, if not overt intimidation, results in pressure on residents to work more than their assigned hours (AMA, 2006; Arora et al., 2008; CIR/SEIU, 2007)
From page 70...
... . Complaints about training program quality including violations of duty hours can be made to ACGME, but those with a complaint are directed before filing a formal complaint to discuss the issues with the local program director or the supervising institutional official responsible for all graduate medical education (ACGME, 2004, 2007a)
From page 71...
... . In New York, the state, not the institution, pays for the reviews of duty hour compliance. For the IPRO contract year 2008-2009, the cost for duty hour review alone is $2.9 million annually, averaging about $24,000 for each of the 124 hospitals under review. New York State has approximately 15 percent of the graduate medical trainees in the country (IPRO, 2007b)
From page 72...
... The committee preferred the third alternative, strengthening the ACGME procedures and providing additional oversight and evaluation by other organizations to ensure that duty hours are considered in the context of quality improvement and patient safety. Below the committee discusses the advantages and disadvantages of each option.
From page 73...
... Its monitoring processes have not been effective in bringing adherence to the duty hour limits that have been in place since 2003. Suboptimal adherence to current limits means their expected positive effect on resident fatigue and patient safety may be less than anticipated to date, making it difficult to assess the national impact of the 2003 duty hour rule changes on patient outcomes, as discussed in Chapter 6.
From page 74...
... This might take the form of an existing organization new to resident hours monitoring, a newly formed and purpose built organization, or one with experience monitoring duty hours at the state level but not nationally. One existing organization that fits the latter category by already performing duty hour monitoring is IPRO in New York State.
From page 75...
... within New York State; more extensive travel requirements likely would mean even higher costs even if they could develop sufficient staff capacity to perform the function. Currently, IPRO's duty hour monitoring function falls under state authority and other than in New York and Puerto Rico there has been limited interest in passing duty hour limits at the state level.
From page 76...
... to complain about duty hour violations directly to the ACGME without first requiring them to go through their program director and the des ignated institutional officer for graduate medical education or (2) to complain to their local institutional compliance office could help address residents' concerns that by reporting onerous working
From page 77...
... These changes recommended by the committee should greatly improve adherence to the duty hour limits. The committee, however, concluded that oversight of the ACGME process was also needed.
From page 78...
... The role envisioned for CMS would be to help ensure the accuracy and reliability of ACGME procedures, data, and reports by supporting periodic evaluations of duty hours that would look not only at compliance but also examine the reasons behind violations and to suggest when exceptions to rules might be necessary to promote patient safety and under what circumstances (e.g., direct supervision) a resident might be able to stay beyond his or her hour limit to participate in an unusual learning opportunity.
From page 79...
... For example, in New York State, fines for duty hour violations are levied on institutions. The committee suggests that ACGME and CMS explore this and other options related to Medicare's program rules for institutions receiving direct or indirect GME funds.
From page 80...
... The oversight role for the Joint Commission would differ from that of CMS and should fit consistently with its own accreditation process, which focuses on patient safety and quality during periodic, unannounced visits to institutions by a team of surveyors. Testimony by the Joint Commission on its approach to monitoring quality of care and safety indicated that rather than monitoring whether resident duty hours meet ACGME limits within an institution, the Joint Commission's approach could be to determine whether residents or other staff were involved in patient safety events examined through patient-centered tracer cases and whether fatigue was a contributing cause (Joint Commission, 2008)
From page 81...
... The loss of accreditation is rare and occurs because of large, serious, and persistent problems. Disadvantages associated with the inclusion of the Joint Commission in the oversight process include the need for the Joint Commission to expand its survey process to include some specific attention to resident fatigue and to adjust its working relationship with other organizations to recognize the duty hour limits set by ACGME.
From page 82...
... • The Centers for Medicare and Medicaid Services should as sess the reliability of ACGME procedures and data and should sponsor periodic independent reviews of ACGME's duty hour monitoring to determine the characteristics of and reasons for violations. • The Joint Commission should seek to ensure that duty hour monitoring is linked to broader activities to improve patient safety in hospitals, including the use of ACGME's adherence data as part of the Joint Commission's hospital surveys and ac creditation actions.
From page 83...
... 2007a. The ACGME's approach to limit resident duty hours 2006-07: A summary of achievements for the fourth year under the common requirements.
From page 84...
... . The ACGME limits on resident duty hours: Standards, promot ing compliance and effect.
From page 85...
... 2006. Baseline duty hours recorded with time-cards: A pre-regulation study of internal medicine residents.
From page 86...
... 2008. Effects of the Ac creditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
From page 87...
... 2005. Impact of duty hour limits on resident training in oto laryngology.


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