New ACGME Standards for Resident Duty Become Effective July 2011

Laurie Barclay, MD

October 14, 2010

October 14, 2010 — The Accreditation Council for Graduate Medical Education (ACGME) has announced the final, updated medical resident duty hour limits and supervision standards that have been approved by the council's board of directors and will become effective July 1, 2011. The ACGME first proposed these new requirements in July, as reported by Medscape Medical News, to provide a comprehensive approach to patient care, quality improvement, supervision, professionalism, transitions in care, and resident well-being.

"These new standards are a cohesive whole," ACGME Task Force Vice Chair and ACGME Chief Executive Officer Thomas Nasca, MD, MACP, said in a news release. "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."

Based on 2008 Institute of Medicine recommendations and a 16-month review of available scientific evidence on sleep issues, patient safety, and resident training, an independent, 16-member task force convened by ACGME developed the new, interrelated standards.

These standards are intended to better match residents' levels of experience and emerging competencies, thereby facilitating safe, quality patient care and improving graduate medical education for the more than 110,000 resident physicians in US teaching hospitals.

Final Standards: Changes

Changes in the final standards include the following:

  • new categories of standards;

  • higher requirements for teamwork, clinical responsibilities, communication, professionalism, personal responsibility, and transitions of care;

  • graduated requirements for minimum time off between scheduled duty periods;

  • increased program and institutional requirements for patient care handovers; and

  • to ensure continuity of patient care, as well as resident safety, there are now more specific requirements for alertness management and strategies to reduce fatigue.

"Residency...is physically, emotionally, and intellectually demanding, and requires longitudinally-concentrated effort on the part of the resident," the final standards read. "Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the resident physician to assume personal responsibility for the care of individual patients. For the resident, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions."

The final standards maintain the current resident duty hour limit of 80 hours per week, averaged over 4 weeks, including all in-house call activities and all moonlighting. On the basis of a sound educational rationale, a review committee may grant exceptions for up to 10%, or a maximum of 88 hours, to individual programs. Duty periods for postgraduate year 1 cannot exceed 16 hours per day.

For postgraduate year 2 residents and in subsequent years, duty periods may be scheduled to a maximum of 24 hours of continuous duty in the hospital. However, programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping is strongly encouraged, particularly after 16 hours of continuous duty and between the hours of 10:00 PM and 8:00 AM.

Importance of Effective Transitions in Care Stressed

The final standards stress the importance of effective transitions in care to patient safety and resident education. Although residents are permitted to remain on site to facilitate patient handovers, this period of time must not exceed an additional 4 hours.

On their own initiative, residents may, in unusual circumstances, remain on site beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such duty extensions are limited to required continuity for a severely ill or unstable patient, academic importance of the developing events, or humanistic involvement with the needs of a patient or family.

"As residents gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence," the standards note. "This concept — graded and progressive responsibility — is one of the core tenets of American graduate medical education. Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to the individual patient; assuring each resident's development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth."

The final standards were drafted by a 16-member ACGME task force of experts in medical education, patient safety, and clinical care. In late June, these standards were first posted for 45 days of public comment, followed by ACGME task force review of comments submitted by more than 1000 interested parties. On the basis of this review, the ACGME requirements committee modified the proposed standards before presenting them to the board for final approval.

The ACGME has also commissioned a cost-impact analysis of the final standards by the same independent organization that conducted the Institute of Medicine cost analysis, and an Institutional Patient Safety and Quality Assurance review approved by the ACGME board will ensure compliance with the final standards.

More information on the new standards is available on the ACGME Web site.

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