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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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 INDEX 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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 INDEX 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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 INDEX 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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 INDEX 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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 INDEX 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