How to Implement Strategies for Change in a Graduate Medical Education Program

James M. Hassett, MD, FACS, Ruth Nawotniak, MS, and Merril T. Dayton, MD, FACS, Department of Surgery, State University of New York at Buffalo

Introduction

In 1989 New York State developed regulations that govern resident working hours.¹ The regulations were created in response to patient safety issues and were designed to ensure the supervision of resident clinical activity. For different reasons, the ACGME has developed and promulgated similar guidelines that apply to resident work hours.² The ACGME guidelines redirect graduate medical education from a service-oriented approach to a career development approach, whereby service is provided in a more effective manner, while educational and professional concepts are emphasized through teaching.

The department of surgery at the State University of New York at Buffalo (SUNYAB) has been successfully addressing New York's regulatory requirements for a long time. We have used a variety of strategies to improve resident efficiency and prioritize their clinical activities to meet specific goals. To accomplish this, we significantly re-engineered the training program. Our experience provides some strategies that might apply to helping others meet ACGME 80-hour work week guidelines.

Background

Both ACGME guidelines and New York regulations limit work hours to 24 consecutive hours with 80 hours of clinical contact in any week, and establish a minimum weekly standard of 24 hours off without beeper call. New York regulations differ from ACGME guidelines in six areas: specifics of direct resident supervision; turnover time activity and duration; time between duty shifts; exceptions for sleep time during on-call assignments; potential for duty hour exception; and regulatory oversight with fines for violations. However, the basic principles are similar. We will not focus on the details of the differences between these principles, although the "devil is in the details." This article provides a summary of the strategies that we have used to address the challenge of training surgeons in an environment where the working hours are limited.

Previously, Dr. Richard H. Bell, Jr., MD, FACS, of the department of surgery at Northwestern University, and his colleagues identified four training program models that apply to the challenge of meeting the ACGME guidelines^3,4. We apply components of three of these "models" in a complex system that provides clinical experience in seven campuses. We use a modified "stretch model" with long assignments at the post-graduate year (PGY) -2, -3 and -4 levels. Within the long assignments, the residents are in a modified "apprentice model" and work with a controlled number of faculty. During each assignment, we use a standard of procedural activity that is linked to the index case load. We expect the resident to show mastery in each assignment in a modified "standards-based model" with a resident credentialing system in a standards-based portfolio to document the development. We do not use the "night float model" because of our concern for continuity-of-care issues in major cases.

Early in the process, we established a start/stop time at 6 AM for most services; identified an end-of-service time between 2 and 6 PM; utilized a 1-in-3 call schedule at all campuses; rescheduled conferences to present them in the turnover time; discontinued a weekend conference schedule; and identified protected time for educational activities during normal business hours. We did not request the exemption for sleep time while on-call, since documentation of the activity appeared impossible to implement.

Challenges and strategies

Challenges arise in the process, regardless of the training program model used. These challenges could be called the "Eight Cs" of compliance:

Strategies to implement in the process require utilization of technology and personnel; documentation of activity; and a focus on specific career-based outcomes. All strategies are designed to improve resident efficiency and maintain a high level of care while complying with work hour regulations.

Caseload

Caseload is the most crucial challenge. The program director needs to identify and prioritize cases. We established a priority system that is based on the procedural needs of a practicing general surgeon and the index cases. Each assignment at every campus is selected to meet specific caseload requirements. Residents understand these caseload requirements and focus their activities toward these cases. We give clear priority to index cases, and services are rated by their ability to generate the applicable caseload. We modify resident assignments based on caseload and reduce redundancy by identifying cases that exceed our requirements or are a low priority and are therefore not "career enhancing." We assign residents to those services with excellent faculty, a good caseload, and a balanced experience. We also limit procedural activity and ration resident time and effort. For example, we limit resident opportunities to provide central lines for angio access to those patients who are admitted to the surgical service. This limitation reduces the number of consults for central lines and significantly improves the time available for other surgical service activities. Furthermore, we use a computerized database with weekly reporting of activity, specific procedural standards—which are based on index cases, and frequent feedback. Residents provide the data for their cases. Staff members enter the data and accuracy is checked weekly or monthly depending on the campus. At the junior level, a report of the resident's cases is provided quarterly. At the senior level, this feedback occurs monthly.

Contact time

Contact time is the amount of time available for procedural activity. Given the reality of limited work hours, contact time must be used efficiently. In five years, clinical contact time in a traditional call schedule can range from 812 to 1219 days. There are both long (call) and short (precall) days. The actual number of contact days is a function of the training program model, the call schedule, and the management of resident time on weekends. From a contact time standpoint, the most ideal traditional call schedule is 1-in-4. We use a 1-in-3 schedule. On most services, we reduce resident work hours on weekend precall days and transfer these hours to other precall days. This improves our contact time while the elective schedule is being run. We follow case density, or the number of index cases per resident/per day, procedural and case activity after normal working hours, and clinic requirements. We use the data to determine personnel assignments and efficiently use contact time. Scheduling major procedures on call days is the most ideal situation, since this maximizes contact time and improves continuity.

We have achieved limited success in this strategy since it requires control of procedural block time that is beyond the scope of this project.

Commitment

Commitment to the goals of the project is the cornerstone of success. The initial effort to design strategies for changing the process should include a needs analysis and meetings where both faculty and residents can develop a consensus and devise strategic methodologies that result in a cohesive compliance plan. To be successful, both residents and faculty have to be committed to improving time management and creating quality educational experiences. To achieve this commitment, we make all stakeholders aware of the priorities and challenges. This is a constant process that is reiterated frequently. Residents are expected to commit to the strategies of the compliance plan and can be dismissed if they violate the plan. A resident leadership group gives residents an opportunity to contribute to the management and governance of the program, with senior residents acting as supervisors who are expected to manage their services.

The faculty has the greatest challenge in maintaining commitment. Since they have no work hour regulations, they are asked to provide more continuity of care and patient service. However, shifting the burden of service to the faculty has a negative impact on their view of entitlement for themselves and the residents. Since the faculty's commitment to plan goals is often related to the provision of service, we utilize alternate providers to help them. Resident support is not available to those members of the faculty who cannot commit to the principles of resident work hour regulations.

Clinical service development

Clinical service development refers to all facets of health care service. In the traditional training model, residents were the service providers of last resort. Now there are more patients and cases than there are residents, and provision of service when work hours are regulated is a crucial event.

We use a clinical service model that augments resident activity by transferring some service responsibilities to other providers and streamlining some processes of care. This includes the use of Physician Assistants (PAs), Nurse Practitioners (NPs), and Registered Nurse First Assistants (RNFAs). Our most successful strategies are the Registered Nurse First Assistant (RNFA) program and the Preadmission Testing (PAT) program. The RNFA program provides procedural assistance when a resident is not available. The PAT program provides a history and physical evaluation of patients in an ambulatory setting, using data available at the time of admission. The PAT Program significantly streamlines the entry point dynamics and provide intra-operative support when procedures are performed electively in an ambulatory setting. Neither program is imbedded in the teaching service but rather supports it. In addition, we have developed protocols for routine activities like prophylaxis for deep vein thrombosis and respirator weaning. All of these strategies require a tremendous effort, increased personnel and resources, and rely on the skills and expertise of others. As a result, these strategies make residents much more effective, and allow compliance with regulations while providing service.

Continuity of care

Continuity of care is related to communication between team members. Regardless of the "model" used to address work hour regulations or guidelines, all strategies challenge the ability to maintain continuity of care. The administrative turnover is a crucial time since residents who are leaving must turn off their beepers, and the new team must rapidly become familiar with all issues. We have found that using information technology, computerizing patient lists, and accessing patient databases directly is very effective. Continuity is less of a problem in ambulatory services, since residents are not normally involved after discharge and the faculty provides the continuity. The greatest challenge to continuity of care is in an intensive care or trauma service, both of which must provide a high level of service to critically ill patients. We have some success using alternate health care providers who are imbedded in these "24-7" services. Still, we believe strategies that successfully address continuity of care will primarily rely on the faculty.

Communication

Communication is the weakest link in the process. Clinical service development increases the number of providers and the need for communication. Cross coverage is a fact of life that depends on a structured pattern of communication and has a significant impact on continuity of care. Easy access to data in a format that allows data to be used has a significant impact on resident efficiency. Computerization of clinical laboratory results improves efficiency and, although we have not used computerized order entry, it appears very promising. We use E-mail and Web site tools for communication with our residents. Since we use multiple campuses, we are developing materials for educational and interactive distance learning activities that will be located on the university Web site.

Coordination

Coordination is a necessary component and improving coordination is a key strategy. Limiting resident work hours significantly changes the educational environment and increases faculty activity and responsibility. Compliance with work-hour regulations results in a curriculum that relies on the quality of a procedural experience and reduces the emphasis on the quantity of those experiences. This makes the program director's job more difficult. Any compliance plan significantly increases the need for controlled management of the educational experience. The program director must structure training and educational opportunities, improve resident efficiency, reduce unnecessary or low priority activities, and develop alternate caregivers or activities to provide service. This requires data, documentation, and professionalism.

Compliance puts much more emphasis on the ability of the program coordinator to manage the training program, support the development of tools and mechanisms to meet core competencies, and document resident activity. The program coordinator must be skilled in data management, have knowledge of educational concepts and health care-related issues, and possess the management skills to apply them. The role of the coordinator must evolve from a part-time secretarial position to a full-time middle management position with sufficient staff to efficiently manage daily activities and document the processes.

In our program, we hired a Master's degree-holding educator, who is experienced in health care management. We increased the program coordinator's support staff, improved the computer support, increased the expertise, and expanded the coordinator's mission. Additionally, our coordinator created and maintains a database for the management of the educational environment from which information can be gleaned to maintain consistency in the curriculum and control of the schedule. Scheduling is crucial to ensuring consistent experiences. We successfully use these strategies for scheduling: strict control of resident schedules; avoidance of over scheduling; development of a resident reserve for unforeseen emergencies; and use of a block scheduling methodology that includes vacation and ready reserves activities.

Competence

Since competence is not easy to define, it is the most difficult challenge to address. We set department standards, goals and objectives that are linked to national guidelines. Our definition of competence includes mastery level for the index case load. It utilizes a benchmark of case experience in a standards-based program that includes performance on the American Board of Surgery Basic Science and In-service Examination, and faculty evaluations of clinical performance. We developed a resident credentialing process to document the effort to achieve mastery. The resident needs to receive a credential for each experience or assignment. This measure indicates mastery and allows the resident to progress to the next level of training. The resident's effort is collected in a standards-based portfolio. Faculty evaluation, examination performances, resident credentials, grand rounds or clinical conference presentations, and manuscripts or poster presentations are placed in the portfolio. Presently, we are modifying our evaluation program to utilize Web-based activities to improve documentation and data management. Achieving mastery implies competence, but does not necessarily guarantee it. Meeting this challenge is an ongoing process.

Summary

A training program helps a resident learn to provide service in a competent manner and must focus on career development. Residents seek graduate training to enhance their careers, therefore, they want to acquire sufficient procedural skills and the ability to apply them. Thus, career development is their major concern. From their standpoint, the best outcome measures for success are caseload, board performance, and fellowship acceptance rate. We have succeeded in helping them meet their goals, while achieving full compliance with work hour regulations.

To be successful, all stakeholders have to be convinced that their effort results in value and that their professional needs will be met. Developing and managing successful strategies for change must result in a more effective and efficient career development program that complies with work hour guidelines. This process allows each resident the opportunity to achieve educational and professional development. Although we still struggle with some issues, we believe that our program has shown that surgical residency programs can function effectively while following resident-work-hour guidelines.

References

1. New York State Department of Health, Medical Staff in New York Codes, Rules and Regulations, Section 405.4 (b)(6)&(f)(3) Title 10 (1998).

2. ACGME Web Site. Internet (http://www.acgme.org).

3. DaRosa DA, Bell RH Jr, Dunnington, GL: Residency program models, programs and evaluation: results of a think tank consortium on resident work hours. Surgery. 2003 Jan;133(1):13-23.

4. Bell RH: Models of residency rotations. American College of Surgeons Web site. Internet (http://www.facs.org/education/rap/bell.html), July 3, 2003.