Basic Information the Faculty Needs To know.

What is the ACGME?
The ACGME is a private, non-profit professional organization that accredits about 8,000 residency education programs in the United States educating more than 100,000 residents. Its mission is to improve the quality of health care in the United States by ensuring and improving the quality of graduate medical education for physicians. The ACGME is governed by a 27-member Board of Directors, which includes 20 directors appointed by the member organizations of the ACGME, three public directors, two residents, the chair of the Council of Review Committee Chairs and a non-voting federal government representative. The ACGME member organizations are the American Association of Medical Colleges, American Board of Medical Specialties, American Hospital Association, American Medical Association, and Council of Medical Specialty Societies.

What is an RRC?
Each medical or surgical specialty discipline has an ACGME Residency Review Committee (RRC), composed of physicians nominated by supporting organizations (e.g. AMA, medical specialty boards, professional organizations) as well as one or more resident representatives. The RRCs establish program requirements and make accreditation decisions for programs in that specialty and related subspecialties.

Accreditation is granted to a residency training program that is in compliance with the program requirements at the time of the site visit, has successfully addressed all past citations, and, in the opinion of the RRC, meets the criteria and standards for the specialty.

Duty Hours: The Basics
Compliance with duty hour standards is mandatory. Even one violation is too many!
The resident work hour’s standards are as follows:

a.The program must be committed to and be responsible for promoting patient safety and resident well-being and to providing a supportive educational environment.
b.The learning objectives of the program must not be compromised by excessive reliance on residents to fulfill service obligations.
c.Didactic and clinical education must have priority in the allotment of residents’ time and energy.
d.Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.

The program must ensure that qualified faculty provides appropriate supervision of residents in patient care activities.

Duty hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the 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.
a. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
b. Residents must be provided with one day in seven free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call.
c. Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call.

On-Call Activities:

a. In-house call must occur no more frequently than every third night, averaged over a four-week period.
b. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care.
c. No new patients may be accepted after 24 hours of continuous duty.
d. At-home call (or pager call)

1) The frequency of at-home call is not subject to the every-third-night, or 24+6 limitation. However at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident.
2) Residents taking at-home call must be provided with one day in seven completely free from all educational and clinical responsibilities, averaged over a four-week period.
3) When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80hour limit.
Residents are responsible for logging their hours, which are reviewed by the program on a weekly basis.

A Guide for Training Directors and Faculty

David G. Bienenfeld, M.D.

The recent focus by our certifying agencies on resident work hours is only one manifestation of a growing awareness in many sectors of the harmful effects of workplace fatigue on employee performance. In residency training, impaired performance means missed opportunities for learning and, at worst, hazards to patients. Tools to recognize fatigue in your resident are provided below. If a resident appears the resident. Dismissal from duties for the day or for a period of rest (e.g. 30-60 minute nap) may be needed. Any concerns can also be immediately addressed with the program director.

Fatigued Residents Typically Have Difficulty With:

Appreciating a complex situation while avoiding distraction Keeping track of the current situation and updating strategies Thinking laterally and being innovative Assessing risk and/or anticipating consequences Maintaining interest in outcome Controlling mood and avoiding inappropriate behavior

More specifically, signs of fatigue include:

Involuntary nodding off
Waves of sleepiness
Problems focusing
Lethargy Irritability
Mood liability
Poor coordination
Difficulty with short-term recall
Tardiness or absences at work

High risk times for fatigue-related symptoms are:
Midnight to 6:00 AM
Early hours of day shifts
First night shift or call night after a break
Change of service
First 2 to 3 hours of a shift or end of shift
Early in residency or when new to night call

Fatigue can be modeled as the result of forces producing fatigue and forces reversing its effects, i.e. recovery.

Moves to limit fatigue-related problems include:

The 80-hour limitation to which our programs are held will certainly help reduce the total number of hours worked.

In general, the residency workload should allow for as little variation in work schedules as is feasible. Rapid or frequent shifts from day to night work are known to increase the risk of fatigue.
Individual residents may need individualized schedules to accommodate idiosyncratic energy cycles.

Many physical illnesses can present as fatigue and should be ruled out when daytime fatigue seems out of proportion to the resident’s workload. The resident should be encouraged to consult his/her primary care physician. Sleep studies may be warranted.

Depression and other psychiatric syndromes may first be manifest as fatigue. Proper diagnosis and treatment should be recommended.

ACGME Program Requirements For Inpatient Rotations?

Rotation Orientation:
An orientation to the rotation/service is required at the beginning of each month. This orientation serves to make clear to the resident (and remind yourself as a faculty) to the expectations and goals for the month. By doing so, residents know what is expected, and assessment of their performance is enhanced. More importantly, research has shown that residents perform and learn better when given clear expectations. Please note, the program does not allow a failing evaluation if residents are not given an orientation and appropriate timely feedback.

A useful orientation should include:
Review of the rotation schedule, and expectations for attendance: Residents are also expected to alert you to times when they will be away. Please remember that protected times include conferences, lectures and continuity clinic. In addition, residents are not permitted to attend any ambulatory, primary care or subspecialty clinics post call.

1.Review of rotation goals and objectives: Most rotation goals and objectives are quite extensive. You need only to review the major parts, and the resident should be encouraged to read the rest on their own. Goals and objectives serve as “knowledge statements” about what the resident should learn on the rotation. They are an essential roadmap for self-education. If you are unclear what the goals for your particular rotation is please contact the Edith Reynolds in the residency office for a copy.
2. Provision of reading assignments
3. Discussion of how the clinic/rotation works, including role of resident: Residents MUST be able to have first contact with patients and precept afterwards with the attending. They cannot “shadow” or follow along. They must be actively engaged in history taking, physical examination, diagnostic testing and care plan management. Of course, you are encouraged to provide direct observation of the resident when possible.
4. Residents must write notes on the patients they see. On inpatient settings, rounds must occur daily, and residents are expected to present the patient and function as the primary care provider while under the attending supervision.

Resident and Faculty Feedback

The RRC mandates that all residents be provided with feedback on progress at the mid-point of each rotation (formative feedback). The residency office can provide you with the template. If there is more than one faculty member on the rotation, this can be designated to one person, who can share the insights of the group. This feedback should focus on areas of strength and areas of improvement to that point. This is particularly critical if the resident is in jeopardy of not passing the rotation. This feedback does not need to be documented, but it must be given.

End of month feedback is provided by the global evaluation (summative) new innovations, you provide at the end of the rotation. These are described below under “evaluation”.
Faculty is encouraged to go over the evaluation at the end of the month.

Evaluations:
1. Evaluations must be submitted in a timely manner. Ideally, they should be done within one week. Delayed evaluation prevents residents from receiving needed feedback and prevents the program from conducting formal semi-annual evaluations.
2. All faculty should evaluate, regardless of the extent of contact. For example, if you only spend two half-days with the resident, please still evaluate based on that degree of contact. If multiple faculty participate on your rotation, the group may wish to meet and fill out one overall evaluation. Some may worry that they are “Certifying” competency for a resident’s future performance, based on a limited amount of contact. This is one worry you can let go. You are only making an assessment based on the degree of contact. For example, let’s assume you worked with a resident for two half-day sessions. If you mark “competent” on history taking, you are not indicating that the resident is automatically able, then and there, to take histories on any patient without supervision. You are only commenting on how they did for the level of contact you had. The program and program director is responsible, in the end, for signing off that residents and graduates are competent to practice without supervision.
3. Please provide specific comments within the evaluation where indicated. Residents have found specific comments to be the most useful in improving future performance.
4. Residents and faculty evaluate each other through the New Innovations system
5. How to access new innovations

Go to www.new-innov.com/Login/Login.aspx

Please contact Edie Reynolds if you do not know your Institution Login, Username, or Password at Edith.Reynolds@ utoledo.edu or by phone at (419) 383-3687

You are expected to review your evaluations by the residents and accept them on new innovations.

PGY 1 resident must not be assigned more than five new patients per admitting day, additional 2 in house transfer patients from medical services may be assigned. PGY 1 resident must not be assigned more than eight new patients in a 48 hour period. PGY 1 resident must not be responsible for the ongoing care of more than 10 patients.

Resident supervising more than one PGY 1 resident must not be responsible for the supervision or admission of more than 10 new patients per admitting day or more than 16 new patients in 48 hour period. Resident supervising one PGY1 resident must not be responsible for ongoing care of more than 14 patients. Resident supervising more than one PGY 1 must not be responsible for ongoing care of more than 20 patients.

Residents must write all orders for patient under their care, with supervision by the attending physician. Attending physician or subspecialty resident writing an order on a residents’ patient must communicate the action to the resident

Ambulatory Rotation

At least 1/3 of resident’s time should be spent in ambulatory training.

Summary of the UT Internal Medicine Residents Ambulatory Clinical Activities
PGY 1
Ambulatory month 3%

PGY 2
Ambulatory month 3%
Neurology 3%
Elective Clinics 1.5 % (3)4.5%
Geriatrics 3%
Total 13.5%

PGY 3
Ambulatory month3%
Endocrinology2%
Rheumatology2%
Dermatology3%
VA 3%
Total 13%

All levels 10%
Continuity Clinic
Total 10%

% of UT residents ambulatory training 35- 39%.

PGY 1-3 Clinic Numbers July 2007-April 16, 2010*

Name	# of Clinics	# of Patients	Pts/Clinic
Abu Malouh	114	376	3.3
Abuhanttash	103	364	3.5
Aguillon	128	569	4.4
Ahmad	124	454	3.7
Ashraf	116	370	3.2
Badawi	121	386	3.2
Hameed	123	439	3.6
Hassan	121	427	3.5
Jacob	117	466	4.1
Lanka	112	464	4.1
Saikumar	93**	307	3.3
White	119	410	3.4
Average / SD		3.7 ± 0.4

* Based on ACGME rules prior to July, 2009
** Achieved 108 clinics by July 2010

What counts as ambulatory training?

Outpatient subspecialty, GIM Longitudinal Clinic, Ambulatory rotation and the VA clinic.

Continuity Clinic
• Has to have 133 clinics in 3 years effective July 2009 –prior
residents are grandfathered to 108 clinics.
• Data driven feedback – RRC demands we give residents data driven feedback
on patient care
• ABIM practice improvement module
• Utilizing admitting residents ‘scholarly activity’ time
• EMR will ease this burden

Is the ACGME involved in competency-based education?

Yes. In 2002, the ACGME launched its competency initiative, which is called the Outcome Project. The ACGME identified six general competencies patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal skills and communication, and systems-based practice – which are now part of the curriculum in every program. The program director and faculty evaluate residents using the competencies as criteria. In addition, some medical school evaluations and all specialty certifications are also being reorganized into the competencies framework.