ACGME approves graduated standards for duty hours for residents training in accredited teaching institutions

The Accreditation Council for Graduate Medical Education (ACGME) Board of Directors has approved a set of requirements that are a comprehensive approach to patient care, quality improvement, supervision, professionalism, transitions in care, and resident well-being. Included are graduated standards for duty hours for the nation's 111,000 residents training in ACGME accredited teaching institutions. The new standards will go into effect in July 2011.

The requirements for doctors-in-training are a comprehensive package of interrelated standards designed to better match residents' levels of experience and emerging competencies, advancing both graduate medical education and safe quality patient care in the nation's teaching hospitals.

A 16-member ACGME task force represented leading specialists in medical education, patient safety and clinical care including 12 physicians with extensive experience in graduate medical education programs, three residents and a public representative with extensive experience in evaluating health care related issues developed proposed standards for the ACGME Board. The group's co-chairs were E. Stephen Amis, MD, chair of the Council of Review Committees, a group made up of the chairs of the Residency Review Committees that review residency programs in the various specialties, and university chair of the Department of Radiology at Albert Einstein College of Medicine and Montefiore Medical Center in New York, and Susan H. Day, MD, outgoing chair of the ACGME Board of Directors and chair of the Department of Ophthalmology at California Pacific Medical Center, San Francisco.

"These new standards are a cohesive whole," noted Thomas Nasca, MD, MACP, chief executive officer of ACGME and vice chair of the ACGME task force that developed the standards. "Implementing them will require small change in some programs and large changes in others, all with the goals of ensuring patient safety, that the next generations of physicians are well-trained to serve the public and that residents receive their training in a humanistic learning environment."

The standards are based on recommendations made by the Institute of Medicine (IOM) in 2008 and evidence collected during a 16-month review of the scientific literature on sleep issues, patient safety and resident training. The task force heard testimony from more than 100 experts on those topics and received and reviewed statements from 100 medical organizations. The standards retain the current duty hour limit of 80 hours per week, averaged over four weeks, but specify more detailed directives for levels of supervision necessary for a first-year resident (known as a PGY-1). The standards also reduce duty periods of first-year residents to no more than 16 hours a day and set stricter requirements for duty hour exceptions.

Changes include establishing new categories of standards and by setting higher requirements for teamwork, clinical responsibilities, communication, professionalism, personal responsibility and transitions of care. Other items the new requirements address include:

• establishing graduated requirements for minimum time off between scheduled duty periods;
• expanding program and institutional requirements regarding handovers of patient care;
• setting more specific requirements for alertness management and fatigue mitigation strategies designed to ensure both continuity of patient care and resident safety.

The standards were first posted for 45 days of public comment in late June. After the comment period closed, the ACGME task force reviewed and considered comments submitted by more than 1,000 interested parties sharing a range of perspectives. Based on these comments the task force and the ACGME Requirements Committee made modifications in the proposed standards before presenting them to the Board for final approval.

The new standards will be posted on the ACGME website today. The ACGME also commissioned a cost impact analysis of the new standards by the same independent organization which performed the IOM cost analysis. This analysis will be posted on the ACGME website next week.

An Institutional Patient Safety and Quality Assurance review, approved by the ACGME board, is being created that will begin to ensure compliance with these new standards. Under this program, the ACGME will review every institution sponsoring graduate medical education programs, examining their ability to integrate residency education, supervision and fatigue management into their existing patient safety and quality improvement initiatives. An advisory panel comprised of national patient safety experts has been meeting with ACGME to help establish this process.

A complete list of task force members and more information about the new standards and the Institutional Patient Safety and Quality Assurance review program can be found at http://acgme-2010standards.org .