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Index
Residency Review Committees, 14, 15,
A
19, 20, 89, 102, 103, 104, 134, 140,
Access to care, 29, 108, 188 243, 244, 250, 251, 322
Accreditation Council for Graduate Medical role and responsibilities, 20, 32, 36, 47,
Education (ACGME) 49, 57-58, 62, 63, 69-70, 71-72, 73-
2003 rules on duty hours, x, xi, 1, 2, 7, 74, 75-77, 79, 81, 82
8, 10-11, 28, 35, 49, 51, 52-53, 55- sanctions, 70
65, 67, 89 sleep education for residents, 248
accreditation review, 57, 69-70 supervision requirements, 129
accreditation standards, 52-63 Work Group on Resident Duty Hours
adherence to 2003 rules, 47, 55-65 and the Learning Environment, 49,
adverse action rate, 70 51
CMS oversight option, 17, 47, 78-83 Adaptation to duty hour limits. See also
Committee on Innovation, 79, 146 Compliance with current duty hours;
complaint procedures, 18, 82 Schedules and scheduling
core competencies, 149, 277 caseload caps, 9, 94-97, 100, 101-104
Educational Innovations Project, 148 costs, 113, 114-115
government oversight option, 78-80 electronic health records and
Joint Commission oversight option, 17, information systems, 100-101
80-83 funding for, 98
monitoring adherence to duty hours, 15, learning and work environment, 98-99
16-18, 36, 37, 69-70, 73-83 mean duty-hour changes, 55-57
monitoring implementation of number of residency or fellowship
recommendations, 295, 322, 324-325 positions, 105, 108, 113-114
new-organization oversight option, organizational and management factors,
77-78 100-101
recommendations to, 11, 16-18, 23 patient characteristics, 91-93
regulation of residency programs, 32 schedule changes, 8, 99, 105, 106-108
strategies, 105-114
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INDEX
support services, 19-20, 93-94, 101, workload under 2003 rules, 97, 105,
104, 105, 111 131, 132, 133
task factors, 93-97 workload under recommendations, 14,
team factors, 97-98, 105 29, 303, 305, 306, 312
transferring work to other personnel, Australia, 345-346, 348
8-9, 105, 110-114
Adherence to limits on duty hours; See
B
Compliance with current duty hours;
Monitoring duty hours
Balanced Budget Act of 1997, 113
Adverse events. See also Medical errors;
Beck Depression Inventory-Short Form, 169
Preventable adverse events
Bell, Bertrand, 50, 128, 246
defined, 182, 363
Bell Commission, 8, 28, 49-50, 51, 93,
fatigue-related incidence, 80, 189-191
128-129
incidence of, 207
Burnout, 10, 30, 137, 160, 167-168, 169,
Joint Commission tracer-case process,
171, 174-175, 207, 211
80, 81
defined, 165-166, 364
Reason’s taxonomy of contributing
factors, 90
Agency for Healthcare Research and
C
Quality, 5, 23, 29, 39, 78, 79-80,
185-186, 187, 196, 217, 218, 248,
Canada, 11, 346, 348-349
265, 278, 325
Care Transitions Program, 274
American Board of Family Practice, 191
Case mix, 19, 91-92, 142-143
American Board of Internal Medicine, 69,
Caseload. See Workload/caseload
144, 149
Center for Epidemiological Studies-
American Board of Medical Specialties, 73,
Depression Scale, 168-169
145
Centers for Medicare and Medicaid Services
American Board of Surgery In-Training
(CMS), 75
Examination, 145, 199
GME funding, 22, 41, 42, 79, 113, 114,
American Medical Association, 64-65, 73,
298, 299, 300, 319-320
145
Office of Clinical Standards and Quality,
Anesthesiology, 19, 33, 56, 63, 129, 147,
78
161, 208, 270, 341
oversight of ACGME monitoring, 17,
APACHE IV database, 197
47, 78-83
Association of American Medical Colleges,
quality and safety assessments, 75, 185-
73, 125, 319
186, 187
Association of Program Directors in Internal
reimbursement policies, 92
Medicine, 103
Charge to committee, 29-30, 217-218,
Attending physicians. See also Supervision
329-330
of residents
Children’s Hospital Graduate Medical
accessibility/availability, 130, 131, 135
Education program, 300
defined, 28, 363
Clancy, Carolyn, 39, 379
fatigue-related injuries, 161
Cognitive errors, 206
intimidation and humiliation of
Cognitive load theory, 137-139
residents, 64-65, 132, 133
Cognitive performance
perceptions of effects of duty-hour
circadian influence, 220-221
limits, 142, 150
cumulative deficits, 234
responsibilities, 34, 105
extended duty periods and, 191, 223,
training in supervisory role, 131, 133,
224
135-136
handovers and, 269, 276
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INDEX
naps and protected sleep periods and, scheduling factors, 108, 109, 110, 174,
109, 228, 229, 232 349
sleep deprivation and, 6, 107, 191, 219, staffing factors, 113, 197
220, 222-223, 232-234, 236 team factors, 97, 98, 282, 283, 286-287
supervision and, 132-133 Cost containment, 91, 136
workflow fragmentation and, 99 Cost implications
workload and, 19, 96, 137-139, 140 of committee recommendations, 2, 22,
College of Family Physicians of Canada, 315-318
348-349 GME funding, 22-23, 298-302
Colorado, 185 increasing number of residents, 310
Committee of Interns and Residents, 49, preventable adverse events, 314-315,
173, 380 316, 317
Commonwealth Fund, 185-186, 187 substituting other staff for residents, 22,
Communication 28, 29, 41, 69, 112, 113, 114-115,
and continuity-of-care, 21, 98, 107, 266, 197, 297, 316
267, 270, 286-287 Cost model
errors in, 204, 207, 211, 267-268 assumptions, 304-305
in handovers, 40, 102, 107, 204, 207, baseline estimates, 304
267-268, 271-272 components, 303
IT solutions, 280 direct annual cost estimates, 304
Compliance with current duty hours. hierarchical nature of, 304-305
See also Accreditation Council PAE and net costs, 314-315
for Graduate Medical Education; sensitivity analyses, 303, 311-314
Monitoring duty hours; Violations of staffing factors, 113, 197, 303, 305-310
duty-hour limits substitution scenarios, 305-307
caseload and, 9, 38, 96, 102 Council of Medical Specialty Societies, 73
data collection on, 74 Council of Teaching Hospitals and Health
economic issues, 69, 73, 317 Systems, 302, 307, 309, 316
exemptions/exceptions, 12, 13, 15-16, Council on Graduate Medical Education,
35, 63, 74, 78, 249-250 319
schedule and, 108 Cross-coverage, 54, 108, 189, 194, 207,
substantial compliance, 57-58, 60-61, 229, 364
69, 71, 73, 249 Culture of safety, 6, 41
uncertainty about, 37 characteristics, 264
by year of training, 64 error discussion and reporting, 265-266,
Continuity of care 278-279
communication, 6, 21, 98, 107, 266, handover practices, 266-277
267, 270, 286-287 high-reliability components and
educational considerations, 126, 140- practices, 264-265
141, 148-149, 351 Current duty hours. See also Compliance
handovers and, xii, 6, 21, 38, 40, 107, with current duty hours; Limits on
193, 266, 268-269, 270, 274, 275, duty hours
277 and admission of patients, 249
limits on work hours and, 9, 38, 125, changes in mean duty hours, 55-57
194 and chronic sleep deprivation, 235
long-block practice and, 148-149 committee recommendations compared
patient characteristics and, 9, 92-93, 140 to, 245
patient concerns, 39-40 suggested refinements, 54-55
protected sleep time and, 217, 230, 231,
241, 247, 268-269
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INDEX
D caseload and, 101
data availability, 38, 102
Denmark, 345 didactic sessions and study, 98, 106,
Denver Health, 101 141, 143-144
Department of Defense, 22, 23, 32, 79, 251, examination and certification results, 10,
298, 299, 300, 316, 325 144-145, 150, 191, 199
Department of Health and Human Services, perceptions of effects of reforms,
8, 29, 79. See also Agency for 141-142
Healthcare Research and Quality; procedure volumes, 142-143, 145, 150
Centers for Medicare and Medicaid sleep loss and, 191
Services; National Institutes of Educational principles. See also Supervision
Health; U.S. Public Health Service of residents
Department of Veterans Affairs, 113, 325 continuity of care, 126, 140-141
electronic medical records system, 197, graded responsibility model, 126,
272 127-136
error reports, 189, 191 professionalism, 126, 128, 135
GME funding, 22, 32, 298, 299, 318 reflective learning, 126, 138-139
National Surgical Quality Improvement workload-learning balance, 127,
Program, 199 136-140
oversight of resident hours, 79 Educational redesign interventions
patient outcomes after 2003 rules competency-based, 146-147, 355-356
implementation, 196-197 international experience, 354-356
recommendations to, 22, 23, 32, 318, long-block design, 148-149
325 long-term effectiveness, 203
Depression, 10, 30, 109, 159, 160, 165, quality improvement techniques, 149,
166, 167, 168-169, 171, 173, 174, 356
207, 211 simulation-based training, 19, 147-148
defined, 168 surgery program, 199
Dermatology, 33, 49, 56, 62 team training, 131, 133, 135-136,
Diabetes, 171 285-286
Duke University LIFE Curriculum, 248 Electronic medical records systems, 100,
Duty hours. See also Current duty hours; 197, 207, 272-273, 281, 317
Extended duty hours; Limits on duty Emergency medicine, 19, 20, 32
hours; Schedules and scheduling; compliance with duty-hour limits, 56,
Shifts; Workweek 57, 63
averaging, 55 duty-hour limits, 13, 14, 52-53, 245,
definitions, 54 341, 346
demands in medical profession, 34-36 handovers, 267, 270, 271
public perceptions of, 39-40 impacts of duty-hour limits, 145
medical errors, 8, 28, 48, 128-129,
225-226
E number of residents and programs, 33
patient outcomes, 129
Economic issues, 41
shift schedules, 34, 108, 244, 245
cost of committee recommendations, 2,
and sleep deprivation, 162, 170
22, 315-318
Epworth Sleepiness Scale, 170
implementation of 2003 rules, 22, 28,
Errors. See Medical errors
29, 98, 113, 114-115
Ethical dilemmas, 65, 137
Education. See Graduate medical education
Europe, 11, 37, 344-345, 347
Educational outcomes
case mix, 143
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INDEX
European Working Time Directive, 269, and medical errors, 6, 10, 38, 179, 188-
344, 345, 347, 350, 351, 352, 354, 193, 202-203, 204, 205, 209, 217,
356 218, 224, 225, 228, 237, 296, 320,
Evaluation, 3, 17, 18, 20, 23, 24, 47, 72, 321
75, 77, 78, 79, 80 night shifts and, 108, 219
Extended duty hours, 36. See also Shifts and professionalism, 173-174
and cognitive performance, 191, 223, recognition of impairment, 163-164
224 recommendations for prevention and
comparison of provisions, 52-53, 66-67 mitigation, 12-16, 242-243, 296-297
defined, 54, 364 and resident safety and well-being, 160-
education time, 51, 54-55, 68, 108, 140 161, 163-164, 191
fatigue and performance after, 40, 106, significance in medical error, 191
190, 191-193, 226-227 sleep quality and quantity and, 218,
frequency, 15, 106, 162, 164, 187-188, 220, 227, 235-237
191-192, 334-335 time on task and, 68
handover time, 51, 54-55 work-rest-sleep factors, 218-219
length of, 56-57, 201 Federal Aviation Administration, 66
and medical errors, 187-188, 191-192, Federal Motor Carrier Safety
200-201 Administration, 66
and patient admissions, 15, 20, 51, 248, Federal Railroad Administration, 66
249 Federation of State Medical Boads, 251
and patient safety, 223-224 Fellow. See Resident
protected sleep, 229-232 Flexner, Abraham, 136
recommended maximum, 244-246 Float, defined, 54. See also Night float/night
recovery sleep, 12, 14, 16, 18, 164, 192, shift
200, 236, 237-238 Foundation Programme, 355-356
and resident safety and well-being, 160, France, 345, 347
161, 162, 163, 164, 165, 191 Friedmann, Paul, 51
schedule comparisons, 10, 13, 332-333,
334-335
G
transportation industry compared, 66-67
transportation options after, 18, 164
General surgery, 61, 63, 95, 142-143, 147,
violations, 9, 58, 59-60, 61-62, 63, 65,
196, 199. See also Surgical programs
96
General Surgery Board Examination, 199
Germany, 345, 347
F Graduate medical education. See also
Accreditation Council for Graduate
Family practice, 35, 56, 63, 174 Medical Education; Learning and
Fatigue. See also Sleep loss and deprivation work environment
and adverse events, 189-191 apprenticeship approach, 7, 29
caseload and, 68, 218 costs, 7
evidence-based management of, 68-69 deficiencies, 69-70
extended duty hours and performance, didactic sessions and study, 51, 96, 98,
12, 40, 106, 163, 190, 191-193, 218- 106, 109, 126, 132, 141, 143-144,
219, 220 223, 232, 252, 364
injuries to residents related to, 18, 39, funding, 22-23, 28, 32, 41, 42, 79, 113,
160-162, 164, 224, 225-226, 365 114, 298, 299, 300, 319-320
history, 28
learning objectives, 125-126
needs, 37-38
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0 INDEX
number of residents and programs, 30- Health Insurance Portability and
32, 33, 189 Accountability Act, 77
overview, 27, 30-34, 47-48, 90 Health Resources and Services
principles, 126-141 Administration, 22, 32, 298, 299,
regulation of programs, 32 300, 318
specialty programs, 32, 35 Healthcare Cost and Utilization Project,
stipends for residents, 29 195, 196
subspecialty (fellowship) programs, 32, Heavy call, 163
42, 51 Home-call, 105
Hospital at Night program, 356
Hospitalists, 8, 54, 98, 113, 198, 249, 285
H
I
Handovers or handoffs
caseload and, 94-95, 102, 141
and cognitive functioning, 269, 276 Inpatient wards, 61, 91
communication issues, 40, 102, 107, Institute for Healthcare Improvement, 274
204, 207, 267-268, 271-272 100,000 Lives and 5 Million Lives
and continuity of care, xii, 6, 21, 38, 40, campaigns, 194
107, 193, 266, 268-269, 270, 274, Intensive care rotations, 61
275, 277 compliance with duty-hour limits, 61, 71
defined, 21, 364 extended-duty hours, 224
designing interventions, 269-277 handover practices, 108, 132, 204, 271
frequency under 2003 rules, 21 impact of duty-hour reforms, 179, 190,
general guidance for improving, 271-276 195-196, 197, 198, 200-204, 210,
information transfer, 266-267, 272-273 222, 224, 235, 237, 314
innovative strategies, 273-275 international duty-hour limits, 341, 346
international experience, 269 intervention study, 190, 200-204
Joint Commission Patient Safety Goal, learning environment, 34, 190
269-271 medical errors and PAEs, 179, 183, 186-
and learning, 193, 271 187, 190, 192, 195, 203, 210, 222,
limits on duty hours and, 40, 54-55, 235, 314
268-269 neonatal, 30, 100
and medical errors, 21, 107, 179, 189, pediatric, 112
194, 202, 204, 206, 209, 266-269, substitution strategies, 112
274-275, 277, 323 supervision, 130, 132
and patient safety, 21, 40, 107, 193, Internal medicine
267-268 caseload, 19, 95, 103
recommendations, 21-22, 277 combined specialties, 32, 56
scheduling for, 13, 21, 51, 52, 53, 106- compliance with duty-hour limits, 55,
107, 108, 202, 223, 245, 273 56, 63, 65, 96, 108
supervision, 132 duty-hour demands, 35
teaching the process, 6, 275, 276-277 duty-hour limits, 49
team approach, 274, 283, 286 handovers, 268, 271
variability of, 268 impacts of duty-hour limits, 69, 91, 132,
Harvard National Depression Screening Day 142, 144, 167-168, 169, 172, 174,
Scale, 169 196
Harvard Work Hours, Health and Safety long-block training design, 148
Group, 225 medical errors, 206, 207
Health information systems, 100-101, noneducational activities, 93, 111
280-282 number of residents and programs, 33
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INDEX
patient concerns in, 39-40 oversight of ACGME monitoring, 17-18,
procedure volume, 142 47, 80-83
quality improvement techniques, 149 Patient Safety Goal, 269-271
safety and well-being of residents, 160, sentinel events reporting system, 81,
161, 166-167, 172 183, 278
shift schedules, 105, 109 tracer-case process, 80, 81
supervision of residents, 132, 135
International experiences with duty-hour
L
limits. See also European Working
Time Directive
Learning and work environment. See also
Australia, 345-346, 348
Adaptation to duty hour limits;
Canada, 11, 346, 348-349
Educational principles; Educational
competency-based training, 355-356
redesign interventions; Supervision of
consequences and barriers, 11, 54,
residents
349-353
case mix and, 91-92, 142-143
Denmark, 345
caseload/workload, 18-19, 38, 94-97,
enforcement methods, 346-349
136-140
Europe, 11, 37, 344-345, 347
continuity of care and, 126, 140-141,
general overview, 340-344
148-149, 351
handovers, 269, 350
culture of safety, 6, 21-22, 133, 264-266
Ireland, 345
design of, 138-139
labor supply shortages, 342, 350-351
educational and work systems, 90-101
lessons for U.S. programs, 353-356
human factors and system engineering
New Zealand, 11, 345, 347-348
approaches, 99
overview of medical education, 340-341
noneducational activities, 19-20, 72-73,
PAEs, 342-344
93-94, 96, 140
phase-in time, 354
overview, 32-34
quality improvement practices, 356
patient characteristics, 19, 91-93
redesign of education and training
recommendations, 18-22
systems, 354-356
reflective learning, 6, 19, 20, 38, 102,
regulations, 341, 344-346
104, 125, 126, 130, 134, 136-140,
training and education opportunities,
149, 150
351-353
service-education balance, 9, 98-99, 102
transition period, 354
team dynamics, 6
United Kingdom, 54, 269, 339, 341,
workflow fragmentation, 19, 99
342, 343, 345, 347, 350, 351, 352,
Length of stay
355
and educational opportunities, 91, 92,
work schedules, 11, 110, 353
95, 136
IPRO, 57, 58, 59, 60, 61, 62, 63, 70, 71,
impact of duty-hour limits, 198
74, 75, 78
and medical errors, 181, 182, 195, 198
Ireland, 345
workload management and, 96, 285,
306
J Limits on duty hours. See also Adaptation
to duty hour limits; Compliance to
Joint Commission, 36, 280 duty hour limits; Current duty hours;
accreditation process, 80, 81 Monitoring duty hours
complaint process, 81 and access to care, 29
error-reporting system, 183 ACGME 2003 rules, 10-11, 51, 53,
evaluation of medical errors, 287 55-65
adapting to, 55-65
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INDEX
adjustments to, 6, 11, 12, 13, 241-243 diagnostic, 2, 94, 181, 188, 194, 201,
and burnout, 167-168 207, 209
changes in response to, 105-114 fatigue and, 6, 10, 38, 179, 188-193,
committee recommendations, 6, 11, 12, 202-203, 204, 205, 209, 217, 218,
13, 241-243 224, 225, 228, 237, 296, 320, 321
comparison of provisions, 52-53 frequency, 180-188
and continuity of care, 38, 125, 194 handovers and, 21, 107, 179, 189, 194,
data on impacts, 30 202, 204, 206, 209, 266-269, 274-
economic issues, 7-8, 28, 41 275, 277, 323
and education quality, 7-8, 10, 11, 14, in ICUs, 179, 183, 186-187, 190, 191,
28, 29, 38, 98-99, 126, 141-145 192, 195-197, 200-204, 207, 210,
emergency room, 13, 14 222, 235, 266-269, 314
evolution of, 48-55 IT support systems and, 281
exemptions/exceptions, 12, 13, 15-16, learning from, 207-208, 264, 280
35, 63, 74, 78 limits on duty hours and, 10, 193-205,
in-hospital on-call frequency, 13, 51, 59 209-210, 235, 321
and medical errors, 10, 193-205, 209- malpractice claims, 186, 187-188, 189,
210, 235, 321 191, 268, 282, 283
off-duty time, 13, 15, 51, 247 measuring hospital-based rates, 180-188
and patient outcomes, 9, 10, 193-205 medication, 21, 99, 132, 170, 181, 192,
shift-related, 13, 68, 226-227, 244-246 198, 201, 205, 207, 208, 209, 265,
transportation industries compared, 37, 268, 272, 281
65-69 organizational contribution, 205-209,
and well-being of residents, 10, 39, 137, 210-211, 265-266
167-168, 169, 171-172, 173-174 perspectives of residents on, 205-206
and workload and learning, 38, 136-137 procedural, 181, 201, 206, 207, 208
workweek, 65-68, 244 randomized controlled trials, 10, 179,
Long-block practice, 148-149 186, 200, 209
recommendations, 21-22, 280
reduction of, 9, 100, 101, 179, 180,
M 186, 188, 190-191, 193-205, 208,
209-210, 211, 220, 222, 226, 235,
Malpractice claims, 186, 187-188, 189, 266-269, 272, 274, 280, 281, 282,
191, 268, 282, 283 284, 314-315
Maslach Burnout Inventory, 166, 167, 168, reporting, 21-22, 182, 183-184, 185-
169 186, 189, 208, 264, 265, 266, 277-
Medical Advantage Program, 299 280, 286, 322
Medical errors. See also Adverse events; research needs, 211, 250-251
Culture of safety; Patient outcomes; resident involvement, 8, 184, 186-188,
Patient safety; Preventable adverse 200, 201, 205, 209
events root-cause analyses, 189
administrative, 206, 207 schedule and, 186, 187, 189, 190, 191-
caseload and, 10, 38, 179, 189, 201- 193, 198, 200-201, 206, 208, 218-
202, 206, 208, 209, 210, 314 219, 222, 224, 226, 238, 246-247
in communication, 204, 207, 211, self-reported exposure to, 207-208
267-268 sleep time and, 220, 246-247
cross-coverage and, 189, 194, 207 specialty and, 208
data sources and collection, 181-183, supervision and, 38, 129, 179, 188, 189,
186 192-193, 203-204, 207, 208, 209,
defining, 181, 182 210, 225, 283
system strategies for reducing, 266-269
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INDEX
N
teamwork and, 282-284
time on task and risk of, 225-227
Naps, 12, 101, 109, 165, 228, 229,
underreporting, 183
232, 234, 239, 247, 306. See also
universe of, 184-186
Protected sleep; Sleep loss and
workflow fragmentation and, 99
deprivation
year of residency and, 179, 187-188,
National Aeronautics and Space
207, 208, 209, 225
Administration, 251
Medicare. See also Centers for Medicare
National Association of Inpatient
and Medicaid Services
Physicians, 103
Provider Analysis and Treatment File,
National Healthcare Quality Report, 186
196
National Institute for Occupational Safety
reimbursement policies, 129, 300
and Health, 226, 235
Teaching Physician Presence Rules, 130
National Institutes of Health, 23, 251, 325
title XVIII, 50
National Sleep Foundation, 39, 56
Medicare Trust Fund, 78
National Surgical Quality Improvement
MetroHealth, 101
Program, 199
Midlevel providers, 105, 112. See also
National Transportation Safety Board, 68
Nurse practitioners; Physician
Needlesticks. See Resident safety, physical
assistants
injuries
Monitoring duty hours
Negligent adverse events, 182, 187, 190
ACGME (current), 15, 16-18, 36, 37,
Neurology, 33, 105, 143, 174
69-70, 71-74, 249-251
Neurosurgery, 8, 35, 56, 62, 63, 97, 105,
costs, 70, 71, 72, 75, 76
147
ACGME with changes (alternative 3), 76-83
New York
counting each violation, 57-58, 60-61
compliance with rules, 57, 60, 63, 195
documentation requirements, 70
duty-hour rules, 8, 9, 28, 48-50, 51
educational considerations, 72-73, 76
IPRO monitoring of duty-hour rules, 57,
effectiveness, 73
58, 59, 60, 61, 62, 63, 70-71, 74, 75,
evaluative studies, 75, 77, 78, 79, 80
76, 78, 79
frequency of audits, 76
Medicaid Utilization Review/Quality
future approach, 16-18, 71-77
Assurance Agent, 57
methods, 64
medical errors, 185
by new organization (alternative 2),
Medicare Quality Improvement
74-75
Organization, 57
New York State/IPRO, 57, 58, 59, 60,
substitutes for residents, 110
61, 62, 63, 70-71, 74, 75, 76, 78, 79
New Zealand, 11, 345, 347-348
oversight of, 77-83
Night float/night shift, 13, 14, 15, 40, 54,
recommendations, 16-18, 82-83,
109, 337
249-251
Noneducational activities. See
substantial compliance model, 57-58,
Workload/caseload
60-61, 69, 71, 73, 249
Nurse practitioners, 7, 8, 22, 29, 98, 105,
unannounced audits, 47, 57, 70-71, 73,
112, 303, 305, 319, 365
76
Nurses, 22, 42, 65, 94, 97, 99, 110, 161,
whistle-blower protections, 76-77, 79
170, 226, 227, 228, 230, 266, 274,
Moonlighting, 2, 8-9, 13, 16, 98, 113, 114,
283, 303, 307, 311, 319, 350, 351
232, 235, 245, 251-252, 321-322
Motor vehicle crashes. See Resident safety
O
Obstetrics-gynecology, 35, 55, 63, 129, 135,
142, 160, 161, 168, 172, 341
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4 INDEX
Occupational Safety and Health risk to, 10, 22, 28, 30, 38, 40, 95, 102,
Administration, 8, 49, 50, 53, 75 131, 134, 148, 180, 188, 196-197,
On-call frequency, 13, 51, 59, 62, 96 198, 204, 207, 209, 211, 217, 218,
Ophthalmology, 33, 49, 56 219, 226-227, 237, 239, 241, 250,
Orthopedic surgery, 33, 56, 70, 105, 145, 265, 266, 267, 274, 277, 323, 344,
172, 196, 349, 351 348, 354, 356
Otolaryngology, 33, 56, 61 supervision of residents and, 8, 20, 38,
Oversight of ACGME monitoring, 17, 47, 125, 128-129
77-83 Pediatrics, 32, 33, 55, 56-57, 63, 65, 69-70,
112, 129, 135, 142, 145, 161, 162,
163, 164, 168, 169, 207
P Physician assistants, 7, 8, 22, 98, 105, 112,
199, 303, 305, 311, 365
Pathology, 33, 56, 62, 160, 161, 340 Physician extenders, 7, 8, 22, 98, 105, 112,
Patient and Physician Safety and Protection 114, 303, 305, 311, 365
Act, 49, 50, 53 Preventable adverse events. See also Adverse
Patient-centeredness, 80, 173, 206, 272, events; Medical errors; Patient safety
274-275, 286 costs, 314-315, 316, 317
Patient characteristics data sources, 183, 184
and adaptation to duty-hour limits, deaths, 185, 265
91-93 defined, 182
and continuity of care, 9, 92-93, 140 estimates of, 183, 185
and extended duty hours, 9 fatigue and, 190, 191
and medical errors, 211 handovers and, 194, 214
Patient concerns, 39-40. See also Patient impacts of nonfatal events, 265
safety incidence, 186-187, 194, 201
Patient outcomes international experience, 342-344
institution-specific studies, 9, 197-200 malpractice claims, 182, 187-188
interventional study in ICUs, 200-204 reducing duty hours and, 214
nationwide studies, 9, 195-197 scheduling effects, 190, 200-201, 204,
natural experiments, 193-199 205, 209, 210, 323
New York State studies, 194-195 Preventive medicine, 33, 49, 56, 62, 149
schedule changes and, 108 Professionalism, 31, 65, 126
sleep deprivation and, 192, 224 fatigue and, 173-174, 175, 217
supervision and, 129 impact of duty-hour limits, 173-174
Patient safety, 39-41. See also Adverse perceptions of long hours as, 82,
events; Medical errors; Preventable 248-249
adverse events team aspects of, 286
caseload and, 10, 94-95, 102, 137 Protected sleep
data sources for assessing quality and, adherence to, 230-232
185-186 benefits, 229
fatigue prevention and mitigation and, and continuity of care, 21, 217, 230,
190-191 231, 241, 247, 268-269
handovers and, 21, 40, 107, 193, as fatigue countermeasure, 12, 18, 228
267-268 recommendation, 12, 16, 18, 245,
indicators of, 186, 195 247-248
limits on duty hours and, 29, 193-205 residents’ use of, 229-231
measuring, 181-184 supplementary night float for, 229, 306
recommendations, 18-20 Psychiatry, 32, 33, 55, 56, 62, 63, 142
research needs, 7 Public Citizen, 8, 49, 50, 53, 54-55, 75
Puerto Rico, 50, 75
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Q workforce implications of, 11, 318-320
Recovery sleep
Quality improvement organizations (QIOs), duration, 15, 232, 235-237
57, 75, 78, 194 extended duty hours and, 12, 14, 15,
Quality improvement practices, 100 192, 234, 236, 237-238
error reporting, 21-22, 182, 184, night shifts and, 12, 14, 238-240
277-280 and performance, 12, 40, 192
health information technology for six-day workweek and, 240
clinical decision support, 280-282 transportation industries, 235
international experiences, 356 Regulation of duty hours. See also Limits on
team factors, 382-383 duty hours
Quality of care, 129, 137, 190, 194-195, exemptions, 8
198 history, 8, 49, 50, 53, 75, 79
Quality of life, 109, 171-173, 174 implementation of 2003 rules, 8-10,
114, 131, 136
transportation industries, 37, 50, 66-67,
R 68
Research on implementation of
Radiology, 33, 56, 142, 147, 208 recommendations, 23, 24, 250,
Reason, James, 181 322-325
Recommendations Residency Review Committees, 14, 15, 19,
ACGME rules compared to, 12, 13 20, 89, 102, 104, 134, 140, 243,
caseload/workload, 104, 321 244, 250, 251
costs of, 2, 22, 315-318 Resident. See also Specialty; individual
duty hours, 6, 11, 12, 13, 241-243 specialties
error detection, correction, and defined, 31, 365; see also Year of
reporting, 21-22, 280 residency
exceptions to duty hours, 12, 13, 15, 16, education, see Graduate medical
243, 245-246, 250, 252, 297, 324 education; Learning and work
fatigue prevention and mitigation, 12- environment
16, 164, 242-251, 320-321 subspecialty, 8-9, 32, 42, 48, 51, 58, 64,
funding for, 11, 22, 315-318 73-74, 105, 112, 113, 135, 144, 161,
handovers, 21-22, 277, 318 187, 188-189, 190, 202, 228, 235,
learning environment, 18-22, 104 237, 251, 252, 268, 285, 303, 305,
monitoring adherence to duty hours, 16- 306, 307, 308, 310, 312, 320
18, 82-83, 249-251 Resident safety. See also Fatigue; Sleep loss
moonlighting, 2, 13, 16, 252, 322 and deprivation
oversight of ACGME, 17-18, 47, 77, 80, driving incidents, 18, 39, 51, 162-164,
81, 82 165, 222, 224, 225, 236
phased implementation, 11, 24, 320- extended duty hours and, 160, 161, 162,
322, 354 163, 164, 165, 225-226, 235, 237
protected sleep period, 12, 16, 18, 245, improving, 18, 164-165
247-248 night shifts and, 160-161, 162, 239
research and evaluation, 23, 24, 250, physical injuries, 18, 39, 160-162, 164,
322-325 224, 225-226, 365
resource allocations, 11, 22-23, 318 recommendations, 18, 164
safety improvements, 18-20, 164, 321, sleeping arrangements onsite, 165
322 specialty differences, 161
supervision of residents, 20, 133, 322 transportation services, 164, 165
transportation for residents, 2, 18, 164, workweek and, 161
165 year of residency and, 161
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Resident well-being, 39. See also Fatigue; heavy call, 163
Sleep loss and deprivation historical, 28
burnout, 10, 30, 137, 165-168, 169, international experience, 11, 110, 353
171, 174-175, 207, 211, 364 intervention studies, 190, 197-199,
caseload and, 102, 137, 166, 167, 168 200-204
defined, 165 long-call, 106; see also Extended duty
depression and mood, 10, 30, 109, 159, hours
160, 165, 166, 167, 168-169, 171, and medical errors, 186, 187, 189, 190,
173, 174, 207, 211 191-193, 198, 200-201, 206, 208,
limits on duty hours and, 10, 39, 137, 218-219, 222, 224, 226, 238
167-168, 169, 171-172, 173-174 preferred practices, 110
physical health, 170-171, 174, 223 and recovery from work, 240
and professionalism, 173-174, 175, 217 rotations, 34
quality of life, 109, 171-173, 174 short-call, 106
recommendations, 18-20 traditional, 107
shift work and, 107, 108, 109, 169 Scutwork. See Noneducational activities
sleep deprivation and, 225 Sentinel events, 81, 182, 183, 267, 278. See
specialty differences, 166, 167, 169, 174 also Medical errors
work intensity and, 10, 166, 167, 168 Service Employees International Union, 49,
year of residency and, 166-167, 172-173 54-55
Resource allocations. See also Workforce Shifts. See also Schedules and scheduling
implications backward rotations, 239
for fatigue management, 69 day float, 109, 336
phase-in of recommendations, 320-322 day-night shift models, 108-110
recommendations, 22-23 defined, 54, 365
research and evaluation, 322-325 length, 13, 14, 15, 52-53, 57, 66-67, 68,
workforce implications, 318-320 96, 106, 200-201; see also Extended
Ribeiro, Bernard, 352 duty hours
Royal College of Physicians and Surgeons of management strategies, 99
Canada, 348-349 night float/night shift, 13, 14, 15, 40,
Royal College of Surgeons, 36, 352 54, 105, 106, 108, 109, 110, 160-
161, 162, 169, 229-230, 237, 238-
240, 245, 247, 306, 356
S overlap for handovers, 13, 21, 51, 52,
53, 106-107, 108, 202, 223, 245,
Safety. See Patient safety; Resident safety 273
Safety net teaching hospitals, 23, 98, 300- and safety and well-being of residents,
302, 318, 364 107, 108, 109, 160-161, 162, 163,
Schedules and scheduling. See also Extended 164, 165, 169
duty hours; Shifts separation between, 59-60, 61, 62, 66-
admissions flow, 99 67, 245, 246-247, 250
comparison of extended duty periods, transportation industry, 66-67, 68
332-333 Sleep Alertness, and Fatigue Education in
and continuity of care, 21, 108, 109, Residency, 248
110, 174, 349 Sleep education, 16, 18, 165, 190, 227,
and education opportunities, 14, 28, 241, 248-249
105, 106, 108, 109 Duke University LIFE Curriculum, 248
examples, 105, 107-108, 198, 331-337 Sleep efficiency, 229
frequency of changes, 40, 105 Sleep inertia, 227, 232
and handovers, 13, 21, 51, 52, 53, 106- Sleep loss and deprivation. See also Fatigue;
107, 108, 202, 223, 245, 273 Protected sleep; Recovery sleep
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ACGME limits, 235 innovative configurations, 199, 200
acute, 12, 192, 220, 223-225, 227-231 substitutes for residents, 22, 38, 41, 52-
chronic, 169, 192, 193, 232-234 53, 307-310
circadian influence, 51, 68, 108, 109, Statement of task, 5, 28, 29-30, 42, 48,
219, 220-222, 227, 236, 238-240 329-330
and cognitive performance, 6, 99, 109, Substitutes for residents
191, 202, 219, 220, 222-223, 227, adaptation to new rules, 8-9, 105,
229, 232-234, 236 110-114
compensating factors, 192 cost implications, 22, 28, 29, 41, 69,
defined, 192 112, 113, 114-115, 197, 297,
and depression, 167, 169, 193 305-310
duration of work and, 220-221 number needed, 112
educating residents and faculty on, 16, nurses, 111
18, 165, 190, 227, 241, 248-249 physician extenders, 7, 8, 22, 29, 98,
extended duty periods and, 220, 223 105, 111, 112, 114, 168, 297, 303,
and human performance, 6, 12, 159, 305, 311, 319, 365
192, 222-223 physician-level staff, 110, 111, 113, 114
and inexperience in first-year residents, support services, 19-20, 93-94, 101,
225 104, 110, 111
and learning, 140, 227, 232 task-tailored mix, 110-111, 365
naps and, 12, 101, 109, 165, 228, 229, wage substitutions, 307
232, 234, 239, 247, 306 Supervision of residents
need for sleep, 219-222 and cognitive performance, 132-133
on-call averages, 162 communication barriers, 20, 132-136
and patient safety, 223, 225 defined, 128, 134-135
and physical health, 170-171 exemption from duty hour limits and,
prevention, 6, 12-16, 18, 40, 106, 164, 12, 14
165, 201, 227-231, 232-237 experience level for, 134-135
and resident performance, 191, 223-224 on extended shifts, 131
and resident safety and well-being, 222, faculty availability under 2003 reforms,
224, 225, 235, 237 131-132
teamwork and, 98 good practices, 130-131
year of residency and, 219-220, 225 graded responsibility model, 20,
Social Security Act, 50 126-128
Society of Thoracic Surgeons, 103 importance of, 6, 19, 38
Specialty. See also individual specialties and medical error, 38, 129, 179, 188,
case mix exposure, 143 189, 192-193, 203-204, 207, 208,
caseload differences, 19, 94, 95, 96-97, 209, 210, 225, 283
101-104 on night shifts, 131
compliance rates by, 56, 62-63 and patient safety, 8, 20, 38, 125,
GME programs, 32, 35 128-129
and medical error, 208 in practice, 128, 129-130
number of residents and programs by, and quality of care, 129
33 recommendations, 20, 133
and safety and well-being of residents, and reflective learning, 138-139
161, 166, 167, 169, 174 on site, 14, 20, 129, 130, 134, 138-139,
supervision differences, 135 192-193, 199, 281
and team dynamics, 97 specialty differences, 135
volume of procedures by, 142 training for, 131, 133, 135-136
Staffing. See also Workforce implications and well-being of residents, 174-175
and continuity of care, 113, 197
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Support services, 19-20, 93-94, 101, 104, Thoracic surgery, 33, 35, 63, 103, 145, 192,
105, 111 351-352
Surgical programs. See also General surgery; Time off, 51, 52-53, 58, 59-60, 62, 63, 66-
Neurosurgery; Orthopedic surgery 67, 246-247
compliance-with duty-hour reforms, 61, Time on task
62, 63, 198-199 and accident risk, 225-227
injuries to residents, 162 frequency of night shift, 247
medical errors, 188, 195-196, 198-199 and performance, 40
supervision of residents, 129 shift length, 226-227, 244-246
well-being of residents, 167, 172 time off between shifts, 51, 52-53, 58,
System strategies 59-60, 246-247
culture of safety, 264-266 violations, 58
error reporting, 277-282 Training. See Graduate medical training
handovers, 266-277 Transforming Care at the Bedside program,
quality improvement practices, 100, 274
277-282 Transitional year programs, 56, 63, 274
team culture, 100, 282-286 Transportation industry compared, 65-68,
workflow and caseload management, 99
100-104 Trauma and Emergency Medicine
Information System, 199
T
U
Teaching hospitals, See Council of Teaching
Hospitals and Health Systems; United Kingdom, 54, 269, 339, 341, 342,
Education 343, 345, 347, 350, 351, 352, 355
Team and teamwork, 34 U.S. Bureau of Labor Statistics, 35, 307
adaptation to new rules, 97-98, 105 U.S. Medical Licensing Exam, 144
and cognitive performance of U.S. Public Health Service, 298
individuals, 98, 192
and continuity of care, 97, 98, 282, 283,
V
286-287
core components, 284
Violations of duty hour limits. See also
defined, 282, 284, 365-366
Compliance with current duty hours;
fatigue management, 229, 282
Monitoring duty hours
handovers, 274, 283, 286
deterrents to reporting, 64-65, 69, 72-74
impact of duty-hour limits on team
education considerations, 72-73
dynamics, 97
facility rates, 58, 59-60, 71
in microsystems, 100
program rates, 58, 59-60
and patient safety, 6, 282-284
reporting, 17-18, 37, 52-53, 61, 70, 76-
shared responsibility, 283-284
77, 79-80
staff members, 98, 111
sanctions, 52-53, 71, 79
supervision, 283
by specialty, 56, 62-63
systems approach, 99
specific rules, 9, 49, 57, 58-62, 63
and task performance, 94, 282, 284-286
trends, 61, 69, 190
training residents in effective strategies,
underreporting, 64-65, 71, 183
285-286
year of residency and, 208
and well-being of residents, 174-175
TeamSTEPPS™, 272
The Hague Accreditation and Approval
Standards, 57-58
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W and patient safety, 10, 94-95, 102, 137
perceptions of changes in, 142
Well-being. See Resident well-being and performance, 139-140
Whistleblower protection. See Violations of recommendations, 104
duty hour limits, reporting and resident well-being, 102, 137, 166,
Work duration. See Extended duty hours; 167, 168
Shifts; Time on task rotation and, 94
Work intensity specialty differences, 19, 94, 95, 96-97,
and caseload limits, 94, 95, 101 101-104, 140
duty-hour limits and, 14, 89, 97, 101, teamwork and, 97-98
244, 324 by training year, 103
and fatigue, 68, 173, 218, 219 work intensity and, 94, 95, 101, 168
and learning, 19 Workweek. See also Current duty hours;
and medical errors, 179 Limits on duty hours
noneducational work and, 38, 101-102 comparison of provisions, 52-53, 65-69
number of residents and, 354-355 compliance with 80-hour rule, 9, 56, 57,
and professionalism, 176 59-61
and safety and well-being of residents, exemptions, 63
10, 166, 167, 168 first-year residents (interns), 9, 34, 35
Workflow fragmentation, 19, 99 historical, 34
Workforce implications and injuries to residents, 161
of committee recommendations, 11, maximum hours, 12, 13, 14, 28, 49, 50,
318-320 51, 66-67, 244, 305, 341, 344-345,
continuity of care, 113, 197 346, 347, 348, 356
reducing noneducational tasks, 102 and medical errors, 189
staff shortages, 22, 29, 41, 319 and safety and well-being of residents,
Workload/caseload 161, 166
adaptation to duty-hour limits, 9, 94-97, by specialty, 35
100, 101-104 transportation industry, 65-68
and adherence to duty-hour limits, 9, 38,
96, 102
Y
admissions, 15, 51, 91, 95, 96, 103,
104, 136, 248, 249, 305
Year of residency
and cognitive function, 19, 96, 97-98,
and caseload, 103
137-139, 140
and compliance with duty-hour limits,
data sources and collection, 103
64, 208
and education outcomes, 102
and medical errors, 179, 187-188, 207,
and fatigue, 68
208, 209, 225
for fully trained physicians, 103
PGY-1 (first-year/intern), 2, 9, 20, 29,
and handovers, 94-95, 102
31, 34, 35, 47, 55, 56, 58, 60, 61,
impacts of 2003 duty hour rules, 95
64, 92, 93, 97, 103, 111, 130, 135,
and learning, 6, 18-20, 96, 102, 136-140
144, 160, 161, 162, 166, 170, 179,
and length of stay, 95, 96, 136
186-187, 188, 191, 199, 200-201,
management strategies, 96, 97-98, 100,
202, 204, 208, 209, 219, 222, 225,
136-137, 168
229, 237, 273, 286, 303, 304, 305,
and medical errors, 10, 38, 179, 189,
306, 307, 308, 310, 311, 312, 349,
201-202, 206, 208, 209, 210, 314
365
noneducational activities and, 19-20,
72-73, 93-94, 96, 102, 104, 140
optimizing, 19-20, 102, 139-140
and patient outcomes, 94
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400 INDEX
PGY-2 (second-year), 8, 31, 34, 55, 56,
60, 62, 93, 130, 135, 161, 170, 172,
199, 208, 219, 225, 237, 286, 312,
365
PGY-3 (third-year), 31, 135, 191, 286
PGY-4 (fourth-year), 172, 286
PGY-5 (fifth-year), 93, 142-143, 172,
286
PGY-6 (sixth-year), 172
and safety and well-being of residents,
161, 166-167, 172-173
and sleep deprivation, 219-220, 225
and workweek, 9, 34, 35
Z
Zion, Libby, 8, 20, 28, 48-49, 128-129
