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ACS Presentations
(Resident Work Hours Issues):
Graduate Surgical Education in the Era of the 80-Hour Workweek

ACGME Program Requirements

RRC Procedures for Granting Duty Hour Exceptions

Options for monitoring compliance with the 80-hour work week readily exist in today's graduate medical education environment

Lynn Chao, MD, FACS
Marc Wallack, MD, FACS
St. Vincent's Catholic Medical Center, New York, NY

The national requirement of the 80-hour work week by the Accreditation Council for Graduate Medical Education (ACGME) has posed new challenges for surgical residency programs. The most obvious and difficult is the actual implementation of schedules that fit within 80 hours, conform to other ACGME work hour requirements, and still provide residents with satisfactory training within five clinical years. The challenges associated with the work hour restrictions have generated much angst for surgery chairmen, program directors, and hospital administrators alike. However, restructuring residencies in such a manner represents only one of the challenges facing these educators. Equally important for residencies is the ability to monitor and document compliance with the ACGME requirements. Monitoring and documenting activities are crucial, as residencies must adequately demonstrate to ACGME reviewers that the system established to meet the requirements actually works and that the programs are aware of any problems. The various aspects to demonstrating compliance are three-fold: documentation tools, resident participation, and evaluation.

Documentation Tools

The concept behind documentation tools is simple: be able to show that the residents are working no more than 80 hours per week, 24 hours per shift, are getting adequate rest. In order to achieve this objective, various programs have developed their own methods for recording work hour-related data. Perhaps one of the more meticulous and labor-intensive methods consists of residents recording their actions for each work hour of the day and for every day of their residency. At our program, St. Vincent's Catholic Medical Center in Manhattan and Staten Island, the residents are required to fill in a timesheet for which every hour is accounted. Codes describing their activities are used to qualify each hourly increment (see Table). The program at Long Island Jewish Hospital goes into even further detail. For example, patient care (Code "PC" in the St. Vincent system) must be broken down into the specific activity like OR, clinic, or floor work. These detailed systems require high compliance from residents and scrutiny by the program administration but do provide accurate descriptions of resident activity and time usage. Other, less detailed reporting methods are also widely used. Some programs have residents just record the amount of time on each activity (ie, 6 hours patient care, 2 hours educational time) rather than explain each hour of the day. Another, even more simpler method is to have residents just log the time in and out of the hospital.

Table: Sample timesheets

The resident must fill each hour box with one of the following code:

PC: Patient care during working day
TT: Transition time = sign out rounds
RE: Required educational activities
VE: Voluntary educational activities
TO: Time off
HC: Home call
OCR: On call resting
OCI: On call interrupted
MA: Moonlighting activities

At the University of California, San Diego, program, the university itself has developed a questionnaire, to be completed by residents monthly, that asks questions such as "Averaged over the past four weeks, have your duty hours exceeded 80 hours per week?" and "Are you overly fatigued (ie, sleepy) as a result of your training program's activities?" These less detailed systems are useful in that such systems require less work on the part of the resident and administration, provided that the programs can prove that the residents' schedules solidly adhere to the time restrictions.

The mediums through which work hour-related data can be collected are paper versus electronic. With the simplest medium, residents place pen to paper, as they do in our program. The time honored pen-and-paper system is obviously inexpensive, and it requires little training on the part of the residents. Some program coordinators also prefer the pen-and paper method as it allows them freedom from working on a computer in order to monitor resident compliance. However, any sort of manipulation and calculations with the data, such as averaging over a period of time or counting number of violations, must be done by hand or entered manually into a database.

Electronic systems are definitely the wave of the future. Many different software companies now offer various products to track hours online. Some companies offering such software include GMEsystem.com from Akcia, Meditrek.com, 80hours.com, and OnCall from Spiral Software. Human resources systems like Kronos® can also be adapted to serve in an hour tracking function. The basic principal with all these products is that residents can access a Web site and log their hours. The program administration can then track work hours, generate reports, monitor completion rates, be alerted of violations, etc. Most of these products are multi-functional in that they also allow usage such as resident scheduling and online resident/faculty evaluation systems. Special features can also be created. For example, Meditrek can create a default schedule so that if a resident's schedule matches the default, he/she merely has to hit one key and the hours are logged, rather than entering all details. Meditrek also has different versions, one for the New York regulations and one for the ACGME regulations. Another feature offered by some products is the ability to enter the hours on a PDA and then transfer the information directly into the system from the PDA. Overall, the Web-based systems are efficient, allowing better data manipulation and comprehensive monitoring but are more expensive and require more time from residents.

The utilization of badge readers, biometrics, telephone log-in, or keypad entry are electronic mediums that do exist apart from the Web-based systems. In hospitals where badges, finger-prints, telephone log-in, or coded pads are required for security purposes or for human resources' payroll, a system can be adapted to track residents' time into and out of the hospital. For example, the program at Christiana Care Health system in Delaware had the security department outfit the residents' call suites with electronic badge readers. These badge readers, unlike the others throughout the hospital, are used strictly for monitoring hours, not for security. Residents flash their badges at the readers upon arrival and departure from the hospital daily. The security department then generates a report for the residency program administration at the end of a rotation with the residents' hours. This system, while providing no details as to actual resident activities, is objective and easy, as long as some security system or human resource product like Kronos already exists in the hospitals at which residents rotate. Residents merely have to acquire the habit of logging in.

Resident Participation

Once the tools for documentation are in place, the biggest hurdle is obtaining resident participation, as residents are the ones who are the initial users of the tools. User friendliness of the tools, monitoring frequency, and administrative enforcement are three aspects that will determine the level of resident participation. The user friendliness of the tools was described in the previous sections. The frequency of monitoring also plays a crucial role in resident participation. It can range from daily to every few months. The more frequent the monitoring, the more difficult initially for compliance but, after a while, the residents get accustomed to the process. Administrative enforcement, however, is key in maintaining resident participation and in ensuring accuracy in reporting. Most programs have the coordinator or director pressure residents to comply with the documentation system in a timely and accurate manner. Some ideas to pro-mote compliance include linking compliance with payroll to ensure prompt reporting and performing internal surprise reviews to detect accuracy of reporting. One former program director reported that he would personally page post-call residents, check the floors and ORs for post-call residents, and look at OR logs, to ensure that the residents were really leaving when they reported that they were. Such enforcement takes dedication on the part of program administration but does ensure prompt and truthful reporting on the part of the residents.

Evaluation

A brief but important mention must be made regarding the third aspect of monitoring: evaluation. Once the hours have been collected, programs usually report the data to another administrative body, like a graduate medical education committee or a quality improvement committee, as well as to the ACGME. Therefore, it is essential that programs review their own data to determine what areas may need to be more closely examined and restructured. For example, this may mean reconfiguring call schedules, redesigning the documentation tool, or changing monitoring frequency. Whatever the case may be, evaluation is the end point of monitoring.

Conclusion

The 80-hour work week is a true challenge to all medical educators, and probably more so for surgical educators. Most programs now recognize that the work-hour restriction situation is permanent and must be adapted to. Adherence includes the monitoring of residents to maintain the 80-hour work week. However, it is important to remember that in this quagmire of monitoring and documenting the real goal behind the efforts is to improve the quality of life and the educational process for the residents. Programs must find methods of monitoring that allow them to not only demonstrate work hour compliance but also make more informed evaluations of the residencies.

Revised January 18, 2005