Transcript Program Directors’ Meeting

November 18, 2010
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: [email protected]
 Rock Away the Blahs
 February 19, 2011; Canner Ballroom - tentative
Agenda
 ACGME Resident Survey
 Monitoring Committee
 Common Program Requirements
 Duty Hours
 Supervision
 Transitions in Care
Resident Survey Content
 Five Main Areas
 Faculty
 Educational Content
 Evaluation
 Resources
 Duty Hours
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?
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
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
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
The Monitoring Committee
 Independent of RRCs but feeds information to them
 4 programs here affected in last 2 years
 5 levels
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)
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)
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)
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)
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.”
Questions?
http://acgme-2010standards.org/
 Section VI – Resident Duty Hours in the Learning
and Working Environment
 Professionalism, Personal Responsibility, and Patient
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Safety
Transitions of Care
Alertness Management/Fatigue Mitigation
Supervision of Residents
Clinical Responsibilities
Teamwork
Resident Duty Hours
Task Force Processes
 Extensive Data-Gathering
 National Duty Hour
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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 –
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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
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
Where are the changes?
 Introduction – statement of principles
 Section VI – Resident Duty Hours in the Learning
and Working Environment
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
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
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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
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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
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.
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
Exercise
 Ideal Supervision
 What are my program’s strengths?
 Where is this problematic for my program?
The Superb/Safety Model
 http://www.jgme.org/doi/pdf/10.4300/JGME-D-09-
00015.1
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
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
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
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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
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.
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
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)
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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