1. November 18, 2010

2. Announcements ACGME Annual Educational Conference Nashville, March 3-6, 2011 Second Look Weekend – Physician Scientists January 20-22, 2011 Second Look Weekend – Underrepresented Minorities February 3-5, 2011 EDP Workshop – “Communicating with Healthcare Team Colleagues in Ways that Promote Collaboration …” Dec 14, 2-4pm, PRB 898-K RSVP: medical.education@vanderbilt.edu Rock Away the Blahs February 19, 2011; Canner Ballroom - tentative

3. Agenda ACGME Resident Survey Monitoring Committee Common Program Requirements Duty Hours Supervision Transitions in Care

4. Resident Survey Content Five Main Areas Faculty Educational Content Evaluation Resources Duty Hours

5. RS: Faculty Do the (or your) faculty: …spend sufficient time teaching? …spend sufficient time supervising? …regularly participate in organized clinical discussions? …regularly participate in rounds? …regularly participate in journal club?

6. RS: Educational Content Access to program’s written goals and objectives Access to written goals and objectives for each rotation and major assignment Fatigue and sleep deprivation education Opportunity for research or scholarly activity Emphasis of education over service obligation

7. RS: Evaluation Opportunity to evaluate faculty annually Opportunity to evaluate program annually Receive rotation or assignment feedback Ability to review current and past evaluations Opportunity to assess program for improvement purposes

8. RS: Resources & Duty Hours Do non-program trainees interfere with your education? Mechanisms available to raise and resolve issues without fear of intimidation or retaliation How often are you able to access needed specific and reference materials? Duty Hour Questions Including moonlighting counted

9. The Monitoring Committee Independent of RRCs but feeds information to them 4 programs here affected in last 2 years 5 levels

10. Category 1: The Worst Definition: Duty hour non-compliance in two consecutive years of the last three years or Duty hour non-compliance in two of the last three years, and non-compliance in >=4 FS areas in last year, or Duty hour non-compliance last year and non-compliance in >=4 FS areas last year, AND problems in >=2 FS areas over the last two years. RRC Action: If not already scheduled, site visit in 6 months. (1 program here in last 2 years)

11. Category 2: The Distressed Definition: 1. Duty hour non-compliance in last year, and 2. Non-compliance in >=4 FS areas in last year. RRC Action: If not already scheduled, site visit in 6 months. (Note: RRC is allowed discretion with appropriate rationale to ACGME)

12. Category 3: The Warned Definition: 1. Duty hour non-compliance in last year, and 2. Non-compliance in 1 – 3 FS areas last year. RRC Action: Letter from the RRC Executive Director and the IRC Executive Director cautioning programs and institutions. (2 programs here in last 2 years)

13. Category 4: The Fence Definition: 1. Duty hours compliant. 2. Non-compliance in 2+ FS areas for past 2 consecutive years, or 3. Non-compliance in 4 FS areas last year. RRC Action: If site visit >1 year, Committee will review the specific program and consider shortening the cycle or a cautionary letter from the RRC Executive Director. (1 program here in last 2 years)

14. Category 5: The Watched Definition: 1. Duty hours compliant. 2. Non-compliance in 2 or 3 FS areas last year. RRC Action: Letter from the RRC Executive Director that “we are watching you.”

15. Questions?

16. http://acgme-2010standards.org/ Section VI – Resident Duty Hours in the Learning and Working Environment Professionalism, Personal Responsibility, and Patient Safety Transitions of Care Alertness Management/Fatigue Mitigation Supervision of Residents Clinical Responsibilities Teamwork Resident Duty Hours

17. Task Force Processes Extensive Data-Gathering National Duty Hour Congress, June 2009 10 meetings from 7/09-4/10 3 independent literature reviews – GME, sleep issues, patient safety Web-based survey – DIOs, PDs, faculty, residents Position statements - >100 med orgs, 100 individuals; US, Canada, UK 4 members of IOM cmte Expert testimony 2003 duty hours standards – history and impact ACGME Monitoring Committee Sleep physiology, research IOM Report & duty hours – historical/political framework Teaching hospital role – patient safety, quality Safety net hospitals New York hospitals’ experience Legal perspective – duty hours Fatigue management/mitigation strategies Public patient safety advocates

18. Objectives & Guiding Principles Patients receive safe, quality care in the teaching setting today Residents provide safe, quality care in future independent practice Clinical learning environment – humanistic, professional Self-regulation of the profession Coherent standards – not simply duty hours One size doesn’t fit all – levels, competencies - milestones Bready, AAMC-GRA 2010

19. Where are the changes? Introduction – statement of principles Section VI – Resident Duty Hours in the Learning and Working Environment

20. New- Duty Hours Up to 80 h/wk, averaged over 4 wks All moonlighting counts Continuous duty PGY-1 residents – up to 16 h PGY-2 and up – up to 24 h (should nap) + 4 h for transition of care Unusual circumstances past 28 - must be monitored, individual In house call frequency – up to q3, avg (unchanged) Minimum 1 day in 7 free, averaged (unchanged) Maximum 6 consecutive nights on night float

21. New- Duty Hours (con’t.) Minimum time off between duty periods PGY-1 residents should have 10 hours and must have 8 hours free of duty between scheduled duty periods Intermediate-level* residents should have 10 hours free of duty and must have 8 hours between scheduled duty periods Must have at least 14 hours free of duty after 24 hours of in-house duty Senior level residents* should have 8 hours between scheduled duty periods May return to duty with fewer than 8 hours – to be defined by RRC This early return to duty must be overseen by the program director

22. New – Supervision Levels Direct Supervision - The supervising physician is physically present with the resident and patient. Indirect Supervision Direct supervision immediately available – The supervising physician is physically within the confines of the site of patient care and immediately available to provide Direct Supervision. Direct supervision available – The supervising physician is not physically present within the confines of the site of patient care, is immediately available by phone, and is available to provide Direct Supervision. Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

23. New – Supervision (cont.) Supervising physician Faculty member or more senior resident Delegate portions of care to residents – needs of the patient, skills of resident* Faculty - Sufficient duration to assess knowledge/skills Programs Guidelines for residents to communicate with supervising faculty Resident’s abilities based on specific criteria (“milestones”)* PGY-1 residents May not be alone on a hospital service (either Direct Supervision or Indirect with Direct Immediately Available) *details to come from RRCs

24. Exercise Ideal Supervision What are my program’s strengths? Where is this problematic for my program?

25. The Superb/Safety Model http://www.jgme.org/doi/pdf/10.4300/JGME-D-09- 00015.1 http://www.jgme.org/doi/pdf/10.4300/JGME-D-09- 00015.1

26. New – Clinical Responsibilities The clinical responsibilities for each resident must be based on: Patient safety PGY-level Demonstrated resident skills/knowledge Severity & complexity of patient illness/condition Available support services Optimal clinical workload specified by each RRC

27. New - Teamwork Residents must care for patients in an environment that maximizes effective communication This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty Further defined by RRC

28. New – Professionalism, Personal Responsibility, Patient Safety Residents must take personal responsibility for, and faculty must model: Safety and welfare of patients; Patient and family centered care; Fitness for duty; Management of time before, during, and after clinical assignments; Recognition of impairment in self and peers; Attention to lifelong learning; Monitoring their patient care PI indicators; Honest and accurate reporting – duty hours, patient outcomes, clinical experience data

29. New – Transitions of Care Design clinical assignments to minimize the number of transitions. Effective, structured handover processes to facility both continuity of care and patient safety. Residents must be competent in communication with team members in the handover process. Schedules that inform (patients and) all members of the health care team of faculty and residents currently responsible for patient care. Residents and attendings should inform patients of their role in the patient’s care.

30. New – Alertness Management All faculty and residents Recognize the signs of fatigue and sleep deprivation Fatigue mitigation processes Naps, back-up call schedules Process – continued care in the event that a resident may be unable to perform his/her patient care duties Adequate sleep facilities and/or safe transportation options for residents who may be too fatigues to safely return home

31. Timeline & Compliance CPRs become effective 7/1/2011 Patient Safety and Quality Assurance review approved by ACGME Board Every sponsoring institution – annual visit (beginning 2012) Integrate residency education, supervision, and fatigue management standards into quality assurance initiatives Projected cost to institution: $12,000-$15,000/yr Results of surveys would be available to the public Details pending