Summary of Proposed Changes to ACGME Common Program Requirements Section VI
Overview
In developing the revised standards, the Common Program Requirements Phase 1 Task Force considered all available information, including relevant literature, written comments received from the graduate medical education community and the public, and testimony provided during the ACGME Congress on the Resident Learning and Working Environment. Deliberations of the Task Force were guided by the need to develop standards that: (1) emphasize that graduate medical education programs are designed to provide professional education; (2) are based on the best available evidence; and (3) support the philosophy outlined in the preamble to the revised requirements.
The revised requirements are intended to promote patient safety, resident well-being, and inter-professional team-based care by providing greater flexibility within an established framework, allowing programs and residents more discretion to structure clinical education in a way that best supports the principles of professional development. With this increased flexibility comes the responsibility for programs and residents to adhere to the 80-hour maximum weekly limit, and to utilize flexibility in a manner that optimizes patient safety, and resident well-being and education. In addition, the requirements eliminate the documentation requirement for residents to justify clinical and educational work hour variations.
Clinical and educational work hours represent only one part of the larger issue of conditions of the learning and working environment, and Section VI has now been expanded to include greater attention to patient safety and resident and faculty member well-being. The requirements are intended to support programs and residents as they strive for excellence, while also ensuring ethical, humanistic training. Ensuring that flexibility is used in an appropriate manner is a shared responsibility of the program and residents. With this flexibility comes a responsibility for residents and faculty members to recognize the need to hand off care of a patient to another provider when a resident is too fatigued to safely provide care and for programs to ensure that residents remain within the 80-hour maximum weekly limit.
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Summary of Changes
VI.A.Patient Safety, Supervision, and Accountibility
These new and expanded requirements have been added in recognition of the need to make explicit that resident education must occur in an environment designed to emphasize a culture of safety and quality improvement, with appropriate levels of supervision and accountability. This increased emphasis on patient safety and quality improvement is expected to improve resident education and patient safety. It is necessary that residents and faculty members consistently work in a well-coordinated manner with other health care professionals to achieve institutional patient safety goals, such as consistent reporting and disclosure of patient safety and adverse events. It is essential that residents learn both to identify the causes of patient safety events, and to institute sustainable systems-based changes to ameliorate patient safety vulnerabilities. This includes receiving data on quality metrics and benchmarks related to their patient populations. Finally, although the attending physician is ultimately responsible for the care of the patient, every physician shares in the responsibility and accountability for his or her efforts in the provision of care. Supervision in the setting of graduate medical education provides safe and effective care to patients; ensures each resident’s development in the skills, knowledge, and attitudes required to enter unsupervised practice; and establishes a foundation for continued professional growth. The revisions to the requirements regarding supervision of residents were made to emphasize the expectation that an individual resident’s level of training and the patient complexity and acuity must factor into decisions regarding the level of supervision provided to that resident, ensuring that the level of supervision is appropriate for each patient.
VI.B. Professionalism
This section describes professionalism in the broad context of what it means to be a physician, including the ultimate responsibility of provision of comprehensive care to the patient. These requirements make explicit that the program director and Sponsoring Institution must ensure a culture of professionalism that supports patient safety and personal responsibility, and that residents and faculty members must demonstrate an understanding an acceptance of their personal role in support of their patients’ safety, including accurate reporting of work hours, patient outcomes, and clinical experience data. Requirements in this section highlight the critical importance of awareness and accountability for fitness for duty, as well as the responsibility of all residents and faculty members to display responsiveness to patient needs that supersedes self-interest. This includes the recognition that under certain circumstances, the best interests of the patient may be served by transitioning care to another qualified and rested provider.
VI.C. Well-Being
The addition of expanded and more specific requirements regarding resident and faculty well-being emphasize the need for programs and institutions to prioritize well-being and recognize that physicians are at increased risk for burnout and depression. Programs and Sponsoring Institutions have the same responsibility to address well-being as they do to ensure other aspects of resident competence. Further, self-care is also an important aspect of professionalism, and a skill that must be learned and nurtured in the context of other aspects of graduate medical education. Promotion of well-being, ensuring protected time with patients, and minimization of non-physician obligations are expected to improve both resident education and quality of patient care. Key components of the requirements of programs and institutions in this area include:
- Helping residents find meaning in work: protected time with patients; minimizing non-physician obligations; administrative support; progressive autonomy and flexibility; enhancement of professional relationships
- Attention to scheduling, work intensity, and work compression
- Evaluating the safety of residents and faculty members in the learning and working environment
- Establishing policies and programs supporting optimal resident and faculty member well-being, including the opportunity to attend appointments for personal care, even during working hours
- Attention to and education in resident and faculty member burnout, depression, and substance abuse in themselves and others; provision of services and resources for care, and tools to identify symptoms and report them; and availability and access to confidential, affordable mental health counseling and treatment, including access to urgent and emergent care 24 hours a day, seven days a week.
- Establishing policies and procedures ensuring continuity of patient care in support of patient and physician safety when residents and faculty members are unable to work, including but not limited to circumstances related to fatigue, illness, and family emergencies.
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VI.D. Fatigue Mitigation
These requirements specify program responsibility related to education of faculty members and residents in recognizing signs of fatigue to ensure continuity of patient care and the provision of adequate sleep facilities and safe transportation options for program residents.
VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care
These requirements define the appropriate level of clinical responsibilities based on resident training level and patient condition, and specify the need for provision of opportunities for residents to work in interprofessional teams appropriate to delivery of care in the specialty or subspecialty and larger health system. Requirements regarding optimization of care transitions in support of continuity of care and patient safety are included here. The requirements make explicit the responsibility of programs and Sponsoring Institutions to ensure and monitor effective, structured hand-over processes, and to ensuring that residents are competent in communications related to hand-offs.
VI.F. Clinical Experience and Education (formerly Duty Hours)
Programs and Sponsoring Institutions must design an effective program structure that provides work-life balance, enabling residents to gain requisite educational and clinical experience as well as reasonable opportunities for rest and personal activities. These requirements encompass the baseline priority for institutions and programs to provide a consistent opportunity for residents to experience an interdisciplinary team-based approach to patient care, safety, physician well-being, and education. Based on thorough review of the best available, current evidence, the cornerstone of these requirements, unchanged since the 2003 revision of the Common Program Requirements, remains the 80-hour weekly limit, one day off in seven, and in-house call no more often than every three days, averaged over four weeks. Programs are responsible for ensuring that residents are provided with manageable workloads that can be accomplished during scheduled work hours. This includes that residents have appropriate support from their clinical teams, and that they are not overburdened with clerical work and/or other non-physician responsibilities.
The terms “clinical experience and education,” “clinical and educational work,” and “work hours” replace the terms “duty hours,” “duty periods,” and “duty” in the proposed revision. This change was made to emphasize that residents’ responsibility to the safe care of their patients supersedes any duty to the clock or schedule.
Changes made in this section include:
- Clinical work done from home must be counted toward the 80-hour weekly maximum.
- Clinical work periods for all residents must not exceed 24 hours of continuous scheduled clinical assignments.
- This change is expected to improve resident education by permitting PGY-1 residents to more fully participate as members of the health care team, with appropriate supervision.
- Clinical work hour exceptions may be granted by the Review Committee to support specialty-specific rotations approved by the institution, for up to a maximum of 88 hours based on sound educational rationale.
- Residents who have appropriately handed off patients following the conclusion of scheduled work periods have the flexibility to voluntarily remain at work in unusual circumstances, if, in their judgment, those circumstances benefit patient care or education. Such additional time must be counted toward the 80-hour limit.
- All residents must have at least 14 hours free of clinical work after 24 hours of clinical assignments. Physicians have a responsibility to return to work rested, and thus are expected to use time away from work to get adequate rest. In support of this goal, residents are encouraged to prioritize sleep over other discretionary activities. Other requirements regarding time off between work periods have been modified to support resident education and patient safety by permitting programs increased flexibility to develop schedules that work best at the local level.