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2
Current Duty Hours and
Monitoring Adherence
In 00, the Accreditation Council for Graduate Medical Education
(ACGME) established a maximum but not required 0-hour workweek
for residents, averaged over 4 weeks. The best available national data
show that first-year residents across various specialties reported working
. hours a week on average during 00-004. Hours of work tend to
be higher for residents in their first year of training, during rotations with
overnight call responsibilities, and for certain specialty programs (e.g.,
general surgery). Lack of adherence to the ACGME limits remains an is-
sue in some programs, particularly with respect to the limitations on the
number of consecutive hours a resident can work and requirements for
adequate time off for recovery sleep and personal activities. As a result,
residents remain susceptible to acute and chronic sleep deprivation, despite
the intent of the 00 duty hour limits to prevent fatigue. The commit-
tee found the need to enhance monitoring of and adherence to duty hour
rules. These changes should include () unannounced audits of duty hours
by ACGME and strengthened whistle-blower protections at the local and
national levels for better detection and resolution of violations; () over-
sight by the Centers for Medicare and Medicaid Services (CMS) and the
Joint Commission of duty hours in relation to patient safety and quality
improvement; and () evaluation of the hours worked and the frequency of
violations, including documentation of their causes (such as patient needs
or unnecessary workload) by specialty.
Residency is a unique career stage, a time to focus exclusively on train-
ing and professional development. Residents experience a sense of growing
every day as they become more competent while performing important,
4
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4 RESIDENT DUTY HOURS
meaningful work. The design of this training ideally maximizes rich edu-
cational experiences and has traditionally meant working long hours. In
settings where camaraderie with faculty and fellow residents is strong,
trainees experience a healthy learning environment and exponential growth
as physicians, not just the fatigue associated with working long hours.
However, concerns have been raised about the quality of care delivered by
fatigued residents and the humane treatment of residents themselves. These
concerns have led to duty hour reforms.
The committee’s task has been to consider whether the current Ac-
creditation Council for Graduate Medical Education (ACGME) duty hour
limits are optimal for resident safety, patient safety, and education. Before
determining this, it was important to understand how the current limits
came to be, whether implementation of any of the limits has been problem-
atic, how the limits have been monitored, and whether data on adherence
to these limits are reliable. Additionally, the committee reviewed duty hour
limits in safety-sensitive transportation industries, including the processes
for establishing regulations in these industries. Based on this appraisal, the
committee makes recommendations in this chapter for future duty hour
monitoring practices at the local and national levels.
SETTING DUTY HOUR LIMITS
Resident work schedules first received widespread public attention in
1984 after the death of Libby Zion, an 18-year-old woman treated in the
emergency department of a New York hospital for fever and earache. Her
family charged that she died due to the poor care by overworked and un-
dersupervised medical residents (no attending physician saw her, although
one was consulted by phone). Upon investigation of her death, a grand jury
in 1986 exonerated the doctors involved in the case (Ludmerer, 1999) and,
instead, faulted the broader system of graduate medical education (New
York Supreme Court, 1986):
the underlying causes of the medical deficient care and treatment in this
case might be prevalent in other Level One hospitals . . . the most serious
deficiencies can be traced to the practice of permitting inexperienced physi-
cians to staff emergency rooms and allowing interns and junior residents
to practice medicine without supervision. . . . Moreover, those patients
who are admitted into these hospitals for treatment are often cared for by
interns and residents who are not required to have contemporaneous, in
person consultations with senior physicians before they initiate a course of
treatment. As a consequence, the most seriously ill patients may be cared
for by the most inexperienced physicians.
The grand jury concluded that the long duty hours of residents at that
time were counterproductive to patient care and to resident learning, and
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4
CURRENT DUTY HOURS AND MONITORING ADHERENCE
it recommended limitations on resident duty hours and enhanced super-
vision (Bell, 2003). During further court proceedings in 1995 related to
Libby Zion’s death, questions continued to be raised about whether duty
hours and supervision were the only contributing factors (Andrews, 1995;
Douglas, 1995). Regardless of the cause, concerns about the circumstances
surrounding her death led to changes in resident scheduling in New York
State and ultimately throughout the country. Table 2-1 outlines changes in
duty hour limits over the past 25 years.
The New York State Commissioner of Health appointed the New York
State Ad Hoc Advisory Committee on Emergency Services, commonly re-
TABLE 2-1 Evolution of Duty Hour Limits
1981 ACGME begins to require “time for rest”
1984 Patient (Libby Zion) dies in a New York teaching hospital, her father
claiming she died due to poor care delivered by overworked, fatigued, and
inadequately supervised residents
1986 Responding to Zion’s death, a grand jury recommends patient care
improvements including limits on resident duty hours in New York State
1987 The Bell Commission recommends specific limits on resident duty hours
and increased supervision of their work
New York State sets duty hour requirementsa
1989
1989-1990 ACGME sets an 80-hour limit in several specialties (internal medicine,
dermatology, ophthalmology, and preventive medicine) and limits in-house
call to every third night with 1 day off in 7 in all specialties, on average
1998 Surprise inspections in 12 New York hospitals find extensive violations of
New York duty hour limits
2001 Public Citizen, Committee of Interns and Residents of the SEIU, and
American Medical Student Association petition OSHA; Representative
Conyers introduces the Patient and Physician Safety and Protection Act of
2001 (not enacted)
2001-2002 ACGME Work Group on Resident Duty Hours and the Learning
Environment develops common duty hour limits for all specialties
2003 ACGME requires current common duty hour limits; Representative
Conyers and Senator Corzine introduce the Patient and Physician Safety
and Protection Act of 2003 (not enacted)
2005 Representative Conyers and Senator Corzine introduce the Patient and
Physician Safety and Protection Act of 2005 (not enacted)
NOTE: OSHA = Occupational Safety and Health Administration; SEIU = Service Employees
International Union.
aNew York State Laws and Regulations: Title 10 NYCRR, § 405.4 (1998).
SOURCES: ACGME, 2007b; GovTrack.us, 2005a,b; IPRO, 2007a; Steinbrook, 2002.
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0 RESIDENT DUTY HOURS
ferred to as the Bell Commission, to investigate the conditions of residency.
The Bell Commission, named after its chair Bertrand Bell, recommended
changes in graduate medical education, including limiting duty hours and
improving supervision of residents. In 1989, as a result of the recommenda-
tions, New York State implemented rules limiting total resident duty hours
per week and the length of extended duty periods, as well as providing
for time off from work to address resident fatigue (Table 2-2).1 Table 2-2
compares New York State rules with subsequent proposals (Public Citizen
petition and legislative proposals) and the 2003 ACGME limits established
for all residencies nationwide.
Attempts to limit resident duty hours through regulatory or legisla-
tive bodies separate from the medical establishment have repeatedly been
stopped both in the U.S. Congress and in state legislatures other than New
York and Puerto Rico (IPRO, 2007a). The ACGME acknowledges that its
“initiative to institute common minimum standards for duty hours unfolded
against a political backdrop in which groups pursued federal intervention
to regulate resident hours” (ACGME, 2003, p. 1; Steinbrook, 2002). Previ-
ously in 2001, Public Citizen petitioned the U.S. Occupational Safety and
Health Administration (OSHA) to establish national duty hour limits for
residents by arguing that long duty hours are physically and mentally harm-
ful to medical residents (Table 2-2) (Public Citizen, 2001). OSHA turned
down the group’s petition in 2002 saying, “Because the issues involved with
medical resident hours go well beyond job safety and affect hospital patient
safety, because other knowledgeable groups are taking action to work on
this problem . . . , the Agency has decided to deny your petition” (Depart-
ment of Labor, 2002).
Several bills to legislate duty hour limits have come before the U.S.
Congress since 2001—all have been referred to committee, and none has
ever been called up for a vote. The most recent bills, introduced by Rep-
resentative Conyers and Senator Corzine, are the Patient and Physician
Safety and Protection Act of 2005 (H.R. 1228 and S. 1297, respectively).
This legislation would have amended title XVIII (Medicare) of the Social
Security Act and authorized the U.S. Secretary of Health and Human
Services to establish regulations on resident duty hours, supervision, and
whistle-blower protections (Table 2-2). The bills would have authorized
funding for training facilities to help meet regulations and required fines
for nonadherence (GovTrack.us, 2005a,b).
1 New York State Laws and Regulations: Title 10 NYCRR, § 405.4 (1998).
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CURRENT DUTY HOURS AND MONITORING ADHERENCE
ACGME 2003 Duty Hour Rules
Beginning July 1, 2003, the ACGME required that duty hours for resi-
dents “must” meet the following provisions:
• An 80-hour workweek averaged over a period of 4 weeks, includ-
ing all in-house calls;
• 1 day in 7 off without any educational or clinical duties or call,
averaged over 4 weeks;
• In-house overnight call frequency of no more than every third
night, averaged over 4 weeks;
• A maximum onsite duty period of 24 hours with up to 6 additional
hours available for didactic education as well as transfer of patients
(residents may not take any new patient after 24 hours on duty);
and
• Although at-home or pager calls do not count toward the every
third night or 24 + 6 hour limit, they “must” not be utilized so
frequently that the resident is unable to rest or to have a reasonable
amount of personal time (ACGME, 2007b).
Additionally, residents “should” have 10 hours off between shifts for ad-
equate rest (ACGME, 2003). The ACGME used “must” to designate man-
datory requirements (ACGME, 2008a). These duty hour limits apply to
trainees in their fellowship years as well.
The 80-hour workweek specified in the New York and ACGME rules
was not empirically determined. The Bell Commission put forth the 80-hour
week using the following heuristic: “There are 168 hours in a week. It is rea-
sonable for residents to work a 10-hour day for 5 days a week. It is humane
for people to work every fourth night. If you subtract the 50-hour week . . .
from 168 hours, you end up with 118 hours. If you then divide 118 by 4
(every fourth night), it equals 30. If you then add 50 to 30, that equals an
80-hour week” (Bell, 2003, p. 40). Similarly, Dr. Paul Friedmann, co-chair of
the later ACGME’s duty hours working group said that 80 hours is “a num-
ber with some general acceptance, without much scientific underpinning”
(Steinbrook, 2002, p. 1298). The ACGME adopted the 80-hour limit to help
protect against the sleep loss associated with working long hours (ACGME,
2003). ACGME indicated that the +6 hours was added to the extended duty
period to prevent residents from driving home at their circadian nadir and
to provide time for learning activities and handover of patient information
(ACGME, 2003).
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RESIDENT DUTY HOURS
TABLE 2-2 Comparison of Duty Hour Provisions
New York Code 405 Rules
(1989, updated in 1998)a
Duty Hour Provisions
Maximum hours per week 80 hours, averaged over 4 weeks
Maximum shift length 24 hours + 3 hours for transitional activities
Maximum in-hospital on-call Every third night, with averaging
frequency
Minimum time off between 8 hours
scheduled shifts
Mandatory time off duty 24 hours off per week, no averaging
Emergency room limits 12-hour limits in hospitals with more than 15,000
unscheduled visits
Whistle-blower protections
Enforcement Civil penalties issued by the state; originally $2,000
per violation; in 2000 raised to $6,000 per item,
plan of correction within 30 days; $25,000 penalty
for noncompliance with correction plan; additional
$50,000 penalty for subsequent noncompliance with
correction plane
Funding (for additional staff Initially, yes;
to make up for loss of resident also funding for compliance monitoring
duty time)
SOURCES: aNew York State Laws and Regulations: Title 10 NYCRR, § 405.4 (1998).
bPublic Citizen, 2001.
cACGME, 2003.
dGovTrack.us, 2005a,b.
eNew York State Department of Health, 2002.
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CURRENT DUTY HOURS AND MONITORING ADHERENCE
Public Citizen
Petition to OSHA ACGME Accreditation H.R. 1228 and S. 1297
(2001)b Standards (2003)c (2005)d
80 hours, no 80 hours, averaged over 4 80 hours, no averaging
averaging weeks; 88 hours for select
programs for a sound
educational rationale
24 hours 24 hours + 6 hours for 24 hours + 3 hours for
transitional activities transitional activities (exception
for patient emergencies)
Every third night, Every third night, with Every third night,
no averaging averaging no averaging
10 hours 10 hours 10 hours
24 hours off per 24 hours off per week, averaged 24 hours off per week, one full
week, no averaging over 4 weeks weekend off per month; no
averaging
12-hour shift limit, at least 12 hours
an equivalent period of time
off between shifts; 60-hour
workweek with additional 12
hours for education
Yes Some confidentiality protection Yes
in complaint procedure
Civil penalties Potential loss of accreditation; Civil penalties, not to exceed
sufficiently large plan of correction $100,000 per training
to deter violations; program in a hospital, with
unannounced corrective action plans to the
inspections Secretary of Health and Human
Services; public disclosure on a
hospital and residency training
program-specific basis
No No Yes, to cover hospital
incremental costs to comply
with regulations
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4 RESIDENT DUTY HOURS
Definition of Terms
ACGME’s definition of graduate medical trainee duty hours includes
all time spent in “clinical and academic activities related to the program,
that is: patient care (both inpatient and outpatient), administrative duties
relative to patient care, provision for transfer of patient care, time spent
in-house during call activities, and scheduled activities, such as conferences.
Duty hours do not include reading and preparation time spent away from
the duty site” (ACGME, 2008a). The term extended duty period (also
known as “long call”) is used in this report to refer to the 30-hour (24 + 6)
maximum continuous duty period allowed under the 2003 limits (ACGME,
2008a). The term shift is applied to any other scheduled period of work,
whether during the day, evening, or night. Residents may or may not have
any time to sleep during extended duty periods, depending on how busy
their service is and the presence or absence of mechanisms for distributing
responsibilities to other residents in a “night float” system or to a hospital-
ist service who will admit new patients or respond to the needs of patients
already in the hospital. On a day or night float schedule, residents are not
assigned to a single service but float across services or teams to help with
admissions and follow-up (PAIRO, 2008). Cross-coverage means being
available to care for patients admitted by other residents when the resident
who has had primary care responsibility for these patients is not at the
hospital or is otherwise unavailable. Other definitions of terms are available
in a glossary in Appendix D.
Suggested Refinements to Duty Hours
The committee heard testimony from organizations representing the
graduate medical education community, which favored continuation of
the current rules over any further reductions in duty hours (AAMC, 2008;
ABNS, 2008; ACGME, 2007b, 2008c; ACS, 2008; AMA Resident/Fellow
Section, 2007). Other speakers, however, pointed out that resident train-
ing in different countries used much shorter workweeks and suggested
that the committee consider shortening the total number of hours allowed
(Landrigan, 2007; Public Citizen, 2007). Speakers from the surgical com-
munity described implementation problems encountered in the United
Kingdom as it has reduced hours substantially. Their perception was that
fewer hours did not ensure sufficient operative experience to attain the
level of competence required for independent practice (ABMS, 2008; ACS,
2008; Royal College of Surgeons of England, 2008). Appendix C contains
an expanded discussion of the lessons from the international experience.
The main objection to the 2003 rules raised in testimony concerned
the extended duty period of 24 + 6 hours. Public Citizen, the Committee
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CURRENT DUTY HOURS AND MONITORING ADHERENCE
of Interns and Residents (CIR) of Service Employees International Union
(SEIU) Healthcare, and Drs. Landrigan and Czeisler advocated that resi-
dents work no more than 16 hours straight, including time for transfer of
patient care and resident education (American Medical Student Association,
2007; CIR/SEIU, 2007; Czeisler, 2007; Landrigan, 2007). The CIR/SEIU
Healthcare also recommended that averaging of duty hours no longer be
allowed in order to prevent large variations in the number of duty hours
from week to week (CIR/SEIU, 2007).
ADAPTING TO 2003 DUTY HOURS
Have duty hours changed in response to 2003 duty hour limits? The
best available evidence shows that mean hours have been reduced over time
(Baldwin et al., 2003; Landrigan et al., 2006). Despite progress in reducing
overall hours, residents and their residency programs do not always adhere
to every aspect of the 2003 ACGME limits (ACGME, 2004; IPRO, 2007b;
Landrigan et al., 2006). Certain elements of the rules are more problematic
than others, and certain specialties have more problems with adherence
than others.
Change in Mean Duty Hours
Mean hours are useful information but they alone do not capture the
variation within and across institutions or specialties. Mean duty hours
for first-year residents (interns) appear to have declined nationwide in
response to duty hour reforms from approximately 83 hours per week in
1998-1999 to 66.6 hours after the 2003 limits. Table 2-3 shows the results
from a national survey of a randomly drawn sample of residents (n = 3,493)
in the 1998-1999 academic year, with interns from two-thirds of special-
ties working more than 80 hours (83.3 hours) on average (Baldwin et al.,
2003). Second-year residents averaged 76.2 hours per week, with one-third
of specialties (all but one a surgical specialty) over 80 hours (Baldwin et
al., 2003). Landrigan and colleagues (2006) looked at the duty hours of
a national self-selected sample of first-year residents (n = 1,278) from at
least 13 different specialties (e.g., internal medicine, pediatrics, psychiatry,
general surgery, obstetrics-gynecology [OB/GYN]) using a monthly web-
based survey to track duty hours. They found a decline from a mean of 70.7
hours before duty hour reform (2002-2003) to 66.6 hours in the first year
of implementation (2003-2004) (Landrigan et al., 2006). The difference
in pre-duty hour levels between Baldwin’s 83 and Landrigan’s 70.7 hours
may be due to many programs starting to transition to expected limits
even before the ACGME limits became official, although it may also reflect
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RESIDENT DUTY HOURS
TABLE 2-3 Average Reported Weekly Work Hours and Percentage of
PGY-1 and PGY-2 Residents Working Over Proposed 80-Hour Limit by
Specialty, 1998-1999 National Survey
PGY-1 PGY-2
Percent of Percent of
Residents Residents
Working Working
Over 80- Over 80-
Specialty Mean (SD) Hour Limit Mean (SD) Hour Limit
Anesthesiology 78.1 (18.1) 44.1 77.7 (16.2) 42.3
Dermatology 59.9 (16.7) 6.9
Emergency medicine 80.1 (17.5) 41.2 71.0 (15.2) 14.3
Family practice 78.1 (16.1) 39.1 67.6 (17.1) 17.9
Internal medicine 83.7 (15.5) 52.4 77.1 (17.3) 35.6
Internal medicine/pediatrics 81.6 (13.9) 46.7 77.5 (16.5) 37.3
Neurological surgery 110.6 (14.4) 100.0
Neurology 82.4 (17.5) 41.0
Obstetrics/gynecology 90.5 (13.7) 69.5 90.8 (17.1) 71.1
Ophthalmology 72.4 (18.9) 23.1
Orthopedic surgery 94.5 (19.1) 75.9 93.8 (16.3) 70.7
Otolaryngology 88.6 (16.5) 57.7
Pathology 60.8 (16.2) 9.4 56.7 (11.2) 5.1
Pediatrics 81.3 (14.9) 43.6 78.1 (14.9) 36.2
Physical 64.2 (18.6) 27.3
medicine/rehabilitation
Preventive medicine 58.7 (18.9) 0.0
Psychiatry 69.7 (16.5) 20.4 59.2 (14.9) 7.1
Radiation oncology 67.4 (10.8) 9.1
Radiology 66.5 (14.7) 20.4
Surgery (general) 102.0 (16.1) 89.0 105.7 (13.6) 93.3
Transitional year 80.1 (17.2) 38.2
Urology 98.5 (19.3) 66.7
Overall 83.0 (17.7) 49.7 76.2 (19.9) 35.1
NOTE: PGY-1 = postgraduate year 1; PGY-2 = postgraduate year 2.
Reprinted with permission by Academic Medicine. Baldwin, D. C., Jr., S. R. Daugherty,
R. Tsai, and M. J. Scotti, Jr. 2003. A national survey of residents’ self-reported work hours:
Thinking beyond specialty. Academic Medicine 78(11):1154-1163.
methodological differences in sampling and recall period for hours worked.
No other national study is available since the 2003 reforms on mean duty
hours across such a spectrum of specialties; studies tend to be specialty or
institution specific.
Landrigan et al. (2006) also noted a significant decline in the mean
length of extended duty periods from 32.1 to 29.9 hours for interns in
multiple specialties. In a subsequent analysis of the change of pediatric
residents’ extended duty hours in three institutions, Landrigan et al. (2008)
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CURRENT DUTY HOURS AND MONITORING ADHERENCE
found a significant decline in the mean from 29.3 ± 3.2 hours before the
2003 rules were implemented to 28.5 ± 2.4 hours afterward.
Degree of Compliance with Current Limits
The responsibility for ensuring that residents and institutions adhere
to the 2003 duty hour standards falls to institutions themselves and the
ACGME as part of its announced accreditation visits. The ACGME ac-
creditation review occurs once every 1-5 years, or once every 3.7 years on
average (ACGME, 2008b). After 10 years of experience with the 80-hour
workweek, New York State mandated yearly, unannounced audits of its
training institutions because surprise inspections in 1998 found widespread
violations: 94 percent of residents in New York City and 37 percent of
those throughout the rest of the state worked more than 85 hours per
week, and 77 percent of surgical residents in New York City and 60 percent
in the rest of the state worked more than 95 hours per week. Further 38
percent of all residents and 67 percent of surgical residents worked more
than 24 consecutive hours. Emergency room residents were in compliance
with their 12-consecutive-hour limits (DeBuono and Osten, 1998; Kennedy,
1998). To achieve annual review, the New York Department of Health has
contracted with IPRO since 2001 to focus solely on monitoring duty hour
compliance (IPRO, 2008). IPRO, an independent, not-for-profit healthcare
and quality improvement organization, is the New York Medicare Quality
Improvement Organization and its Medicaid Utilization Review/Quality
Assurance Agent. All 124 New York teaching hospitals have monitoring
by both IPRO and ACGME.
Substantial Compliance Versus Counting Each Violation
ACGME and IPRO both use what they term a “substantial compli-
ance model” for monitoring duty hours. Using this model, a program will
not receive a citation for single or isolated violations of duty hour rules.
The violations need to be more systemic. ACGME examines programs
more closely if 15 percent or more residents report violations on three or
more standards through ACGME’s yearly resident survey. IPRO also uses
a threshold of 15 percent for resident nonadherence to a single duty hour
rule before giving a citation. IPRO does not trigger a violation at precisely
the hour limit. Instead 15 percent of residents would have to be over an 85-
hour week average, for example, to trigger a violation or 15 percent would
have to be over 28 hours on an extended duty period (New York limit is
24 + 3 hours).2 Various accreditation bodies (e.g., The Hague Accreditation
2 Personal communication, V. Wilbur, IPRO, June 9, 2008.
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RESIDENT DUTY HOURS
appropriately, and a clean slate with no perceptions of bias. The main dis-
advantages to doing this are similar to those mentioned for a new organiza-
tion to conduct monitoring: delays in getting authority and funds to create
such an organization and the need to establish public credibility. It would
also need to design and establish a mechanism and procedures for providing
oversight. The committee concluded that the delays and expense involved
with creating a new oversight organization were not justified.
Alternative : A Government Agency for Oversight
Some of the advantages of using a public federal agency are that it is
less likely to be co-opted by the profession than are private bodies, it can be
tough and authoritative, and may already enjoy a measure of public trust.
The most obvious government agencies that might conduct oversight of
duty hour monitoring are the Centers for Medicare and Medicaid Services
(CMS) or the Agency for Healthcare Research and Quality (AHRQ). The
specific pros and cons of using CMS and AHRQ are discussed below.
The role envisioned for CMS would be to help ensure the accuracy and
reliability of ACGME procedures, data, and reports by supporting periodic
evaluations of duty hours that would look not only at compliance but also
examine the reasons behind violations and to suggest when exceptions to
rules might be necessary to promote patient safety and under what circum-
stances (e.g., direct supervision) a resident might be able to stay beyond
his or her hour limit to participate in an unusual learning opportunity.
This overview of the exceptions process as well as duty hour adherence is
important in light of the committee’s recommendations on adjustments to
duty hours and provisions for exceptions in Chapter 7.
CMS has an Office of Clinical Standards and Quality (OCSQ) that
serves as a focal point for all quality and safety issues and it has direct
access to funds from the Medicare Trust Fund that support contracts for
research and evaluation related to quality and safety. A very small percent-
age of those funds could support periodic contracted evaluations of duty
hours and their monitoring and their relationship to quality of care, patient
safety, resident safety, and educational outcomes. CMS could either con-
tract for studies of duty hour compliance and manage the contracts directly
or it could support research managed by another federal agency, such as
AHRQ. Alternatively, OCSQ also has ongoing contracts with private qual-
ity improvement organizations in each state, such as IPRO in New York,
and could support one or more of them to conduct an evaluation of the
outcomes of ACGME monitoring on adherence to rules.
There are several reasons why CMS would be the most appropriate
agency to take on some of the necessary evaluative responsibilities, but
also reasons why that might not be desirable. On the positive side, CMS
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CURRENT DUTY HOURS AND MONITORING ADHERENCE
has had an intimate relationship with teaching hospitals since 1965 con-
cerning graduate medical education (GME) funding and resident educa-
tion. It expends more than $8 billion in funds annually related to GME
and associated patient care. CMS is the main federal agency responsible
for assuring healthcare quality, paying for the care of millions of patients
in teaching hospitals, as well as auditing the facilities. In addition, CMS
has had ongoing relations with the VA and DOD health systems over the
years concerning Medicare-eligible veterans and retirees, which might
facilitate cooperative oversight of resident hours in those systems. CMS
has the resources to conduct the evaluative studies envisioned for their
oversight role.
Having CMS involved in the oversight of duty hours monitoring pro-
vides additional possibilities for increasing adherence to the rules. If the
changes in ACGME monitoring practices and whistle-blower protections do
not prove sufficient to have institutions comply, financial levers should be
considered in addition to the threat of ACGME accreditation withdrawal or
placing a residency program on probationary status. For example, in New
York State, fines for duty hour violations are levied on institutions. The
committee suggests that ACGME and CMS explore this and other options
related to Medicare’s program rules for institutions receiving direct or in-
direct GME funds. CMS would want to have confidence in the monitoring
process before leveling such fines and having conducted an evaluation of
the process would be critical. Additionally, ACGME through its Committee
on Innovations may discover that certain carrot-and-stick approaches will
foster adherence and these should also be considered (Volpp and Landrigan,
2008).
On the negative side, CMS is a large bureaucracy that has not done
such oversight of the GME program in the past and that function may not
be a top priority for funding and attention in the organization. Since it is a
federal agency, its policies and staff could potentially change significantly
from one administration to another. Some people might object to giving a
government agency oversight over a private organization’s monitoring of
duty hours as has been evidenced in opposition to previous attempts to
regulate duty hours in HHS through legislation.
While AHRQ might also be an appropriate option for the evaluative
studies, it would likely have more difficulty obtaining needed funds than
would CMS, and it does not have the leverage over training institutions
that CMS has. The committee expects that AHRQ would play a significant
role in implementing the recommendation concerning future research and
evaluation, discussed in Chapter 9, and AHRQ would benefit from having
a neutral role when working with other research-oriented parties planning
a research agenda rather than direct oversight responsibilities. Addition-
ally, the newly initiated AHRQ program on Patient Safety Organization
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0 RESIDENT DUTY HOURS
reporting could yield complementary information on whether residents
and/or fatigue contribute to reported events if resident status and fatigue
are included in those reporting requirements (AHRQ, 2008).
The committee recommends that CMS should provide evaluative over-
sight of ACGME’s monitoring of duty hours and the possible effects of
violations on quality of care and patient safety. That oversight function
would be enhanced by complementary oversight by an existing private
organization as well.
Alternative : An Existing Private Organization for Oversight
An existing private organization conducting related functions could
have certain advantages over both a new organization and a public one.
It could move quickly and readily update its procedures, have stature and
recognition among the profession and the public, and a focus on quality
and safety. The Joint Commission, which currently accredits hospitals,
could play a complementary role to CMS’s oversight of the duty hours
monitoring.
The oversight role for the Joint Commission would differ from that of
CMS and should fit consistently with its own accreditation process, which
focuses on patient safety and quality during periodic, unannounced visits
to institutions by a team of surveyors. Testimony by the Joint Commission
on its approach to monitoring quality of care and safety indicated that
rather than monitoring whether resident duty hours meet ACGME limits
within an institution, the Joint Commission’s approach could be to deter-
mine whether residents or other staff were involved in patient safety events
examined through patient-centered tracer cases and whether fatigue was a
contributing cause (Joint Commission, 2008). For the Joint Commission to
take on this systematic oversight function, it would likely need to adjust its
policies and procedures to include a stronger focus and guidance on fatigue,
safety, and work hours, although it already has raised the issue through
its publications. Since their tracer case process as well as preliminary data
analysis related to each hospital’s accreditation visit include a wide variety
of data and record checks, the marginal increase in work and costs based on
cases with fatigued residents to assure proper monitoring policies and pro-
cedures would likely not be great. The surveyors would not have to check
adherence documentation for all the residency programs in an institution,
just those related to programs in a tracer case.
There are advantages to including the Joint Commission in the over-
sight process. The Joint Commission currently accredits 97.5 percent of
major teaching hospitals and 93.6 percent of minor teaching hospitals
(Joint Commission, 2008). An oversight role would place adherence to duty
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CURRENT DUTY HOURS AND MONITORING ADHERENCE
hours and prevention of fatigue within institution-specific quality and safety
efforts and highlight the role of residents and their importance to patient
safety. Joint Commission accreditation affects the entire hospital not just
the educational programs and, through its recommendations for systems
improvements, receives the attention of institutional administrators. The
accreditation process is used to identify areas for correction and improve-
ment in a hospital (i.e., Requirements for Improvement that facilities must
address specified by surveyors based on findings of deficiencies), and if a
problem concerning adherence to duty hours is uncovered, it should be
treated as other similar violations by the Joint Commission. The loss of
accreditation is rare and occurs because of large, serious, and persistent
problems.
Disadvantages associated with the inclusion of the Joint Commission in
the oversight process include the need for the Joint Commission to expand
its survey process to include some specific attention to resident fatigue and
to adjust its working relationship with other organizations to recognize the
duty hour limits set by ACGME. The Joint Commission’s priorities are on
patient safety and quality issues. Their complaint process, which receives
approximately 12,000 complaints per year, gets only 5-8 related to resident
work hours and their voluntary sentinel events reporting system rarely
finds resident fatigue mentioned in the root cause analyses, indicating that
currently the resident fatigue issue does not demand much attention (Joint
Commission, 2008). It could happen that the Joint Commission’s use of its
tracer case method will reveal very few patient events related to resident
fatigue and duty hours, but that would not necessarily negate the value of
its oversight role.
The committee concludes that the advantages of a strengthened
ACGME monitoring process along with external oversight by both CMS
and the Joint Commission would help assure the public that programs
would be more likely to adhere to the rules, problems with duty hours com-
pliance would be uncovered and dealt with properly, and there would be
more rapid implementation of the committee’s recommended adjustments
to duty hours. CMS, the Joint Commission, and ACGME should discuss
how their functions could complement each other and what information
can be shared. The recommended oversight functions discussed for CMS
and the Joint Commission are designed to be practical, derive from existing
functions, and not be overly burdensome. Also, residents are more likely to
report problems when they arise if probation of their educational program
was not the only lever. The stature of existing relationships of both CMS
and Joint Commission with teaching institutions would significantly add
weight at the institutional level to ACGME processes.
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RESIDENT DUTY HOURS
Recommendation 2-1: ACGME and residency programs should ensure
adherence to the current limits now, and to any new limits when imple-
mented, by strengthening their current monitoring practices. To provide
additional support, the Centers for Medicare and Medicaid Services and
the Joint Commission should take an active oversight role:
• ACGME should maintain responsibility for duty hour moni-
toring and should enhance its procedures by including unan-
nounced visits for monitoring duty hours and regular collec-
tion of sufficient data to understand when and why limits are
violated.
• Sponsoring institutions should provide for confidential, pro-
tected reporting of duty hour violations by residents through
their compliance office or by an entity above the program
level that does not have direct responsibility over the residency
programs.
• ACGME should strengthen its complaint procedures to provide
more confidentiality and protection to persons reporting viola-
tions of duty hours, as well as other violations of residency
rules.
• The Centers for Medicare and Medicaid Services should as-
sess the reliability of ACGME procedures and data and should
sponsor periodic independent reviews of ACGME’s duty hour
monitoring to determine the characteristics of and reasons for
violations.
• The Joint Commission should seek to ensure that duty hour
monitoring is linked to broader activities to improve patient
safety in hospitals, including the use of ACGME’s adherence
data as part of the Joint Commission’s hospital surveys and ac-
creditation actions.
Service demands on residents and educational expectations can create
pressures for longer hours of service than are necessary for achieving edu-
cational competence alone. In instituting the 2003 duty hour reforms, the
ACGME indicated that training programs needed to “decouple notions of
professionalism from the number of hours worked” (AAMC, 2003). Going
forward, professionalism should not just mean staying long hours. Edu-
cational leaders, hospital administrators, and residents themselves should
recognize that ensuring adequate sleep for residents is part of responsible
behavior to promote safe conditions for both residents and patients. This
chapter has focused on the need for increased monitoring of resident duty
hours and increasing transparency of why rules are violated. The commit-
tee’s ultimate intent is not to establish a burdensome and costly monitoring
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CURRENT DUTY HOURS AND MONITORING ADHERENCE
process that must be continued forever, but to ensure that there is a change
in practice and that we learn from its implementation.
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