CIR Summary of Key IOM Work Hour Recommendations
“The nation must take a hard look at its residency programs – including hours, schedules, supervision, patient caseloads and handovers – and ensure that they serve both patient and resident safety today and educational needs for tomorrow.”
-- Resident Duty Hours: Enhancing Sleep, Supervision and Safety
Institute of Medicine, 12/2/08
The Institute of Medicine’s 428-page report on Resident Duty Hours: Enhancing Sleep, Supervision and Safety was prepared at the request of Congress. It is a far-reaching review of medical education in the United States -- far more comprehensive than the chart of recommended changes in work hours found below might suggest.
In addition to determining that “there is enough evidence from studies of residents and additional scientific literature on human performance and the need for sleep to recommend changes to resident training and duty hours aimed at promoting safer working conditions for residents and patients by reducing resident fatigue” (Summary, p. 4), the IOM committee also recommended the following:
1. Workload Limits
ACGME should require each Residency Review Committee to determine and enforce appropriate limits on workload (e.g. number of admissions, cross-coverage, number of surgical cases to assist per day). (Summary, p. 12)
2. Adequate, Direct, Onsite Supervision
Measurable standards of supervision for each level of resident should be put in place and 1st year residents should “not be on duty without having immediate access to a residency program-approved supervisory physician in-house.” (Summary, p. 13)
3. Improved Resident Safety
Safe transportation options (taxi, public transportation vouchers) should immediately be provided by teaching hospitals to residents too fatigued to drive home safely. (Summary, p. 11)
4. Increased Oversight
Independent monitoring from the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission should be provided to ensure adherence to hours limits (current and new), in addition to increased ACGME enforcement of work hours (including unannounced visits, strengthened complaint procedures, and confidential, protected reporting of hours by teaching hospitals). (Summary, p. 11)
5. Structured, Institutionalized Handover Processes
Residents should be trained in effective handover communication and programs should schedule an overlap in time during which teams transition. (Summary, p. 14)
6. Funding for Changes
GME financial stakeholders (CMS, VA, Dept of Defense, states and local governments, private insurers and teaching hospitals, etc.) “should financially support the changes necessitated by the committee’s recommendations to promote patient safety and resident safety and education, with special attention to safety net hospitals.” The cost of hiring staff substitutes, other health care providers or additional residents “could be approximately $1.7 billion (~0.4% of the Medicare budget). Bringing residency programs into compliance with the 2003 limits would require almost one-quarter of that $1.7 billion. (Summary, p. 15)
7. Timetable for Change
“The committee believes that the ACGME and other organizations charged to implement aspects of the recommendations should begin their work with urgency and that action on all recommendations should be taken within 24 months.” (Summary, p. 5)
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