ACGME RRC Update

1
ACGME / RRC Update

• Winter 2007
• John B. Waits, MD
• Residency Program Director

2
February 2005 Citations

• Internal Review
• Resident Attrition
• Faculty Board Certification typos
• Home Visits / Nursing Home Visits
• Maternity Care / Total Deliveries (REPEAT
  CITATION)
• Maternity Care Curriculum
• Neonatal Resuscitation
• Goals and Objectives
• FMC Patient Population / Patient Volume
• Board Scores

3
Internal Review

• not conducted at midpoint
• instead done in Jan 2004
• DONE.

4
(2) Resident Attrition

• 8 residents (22)
• 4 transferred
• 2 withdrawn
• 2 dismissed
• 4 residents since Feb 2005 (11)
• 1 transferred
• 3 withdrawn

5
(3) Faculty Board Certification

• typos

6
(4) Home Visits / Nursing Home Visits

• many graduated with zero documented
• Graduating Class of 2006 33 compliance
• Class of 2007 60 compliance so far

7
(5) Maternity Care / Total Deliveries

• REPEAT CITATION
• Total 40 Continuity 10
• Total
• Class of 2005 0 / 9
• Class of 2006 4 / 12
• Class of 2007 4 / 12 so far
• Continuity
• Class of 2006 2 / 12
• Class of 2007 6 / 12 so far

8
(6) Maternity Care Curriculum

• RRC opinion 3 months of ObGyn
• lt 2 full months OB
• lt 100 hours Gyn

9
(7) Neonatal Resuscitation

• DONE we now get NRP in orientation

10
(8) Goals and Objectives

• faculty unaware of these
• annual review
• www.cchs.ua.edu

11
(9) FMC Patient Population / Patient Volume

• 150 PGY-1, 1650 total
• Class of 2006 7 / 12
• Class of 2007 3 / 12 on pace
• Class of 2008 0 / 12 on pace
• Class of 2009 1 / 12 on pace

12
(10) Board Scores

• 19 failure 1st attempt
• 6 of 32 failed in 2002-2004
• 4 of 13 failed in 2004

13
Feb-Mar 2006 Resident Survey

• You have spoken!

14
Core faculty teach and supervise in ways that
facilitate learning (III.B.4.).
15
Core faculty demonstrate a strong interest in the
quality of residents education (III.B.2.).
16
Residents evaluate the faculty through
confidential written evaluations (VII.B.).
17
Program distributes a written statement of
educational goals to residents
18
Program communicates the results of written
performance evaluations to residents
19
Performance evaluations accessible to residents.
20
Performance evaluations helpful to residents in
improving competence and performance
21
Program responds fairly to resident complaints
22
Program emphasizes practices that ensure patient
safety
23
Residents perform services (start IVs, transport
patients, do routine blood draws) that should be
done routinely by support staff
24
Program has sufficient professional, technical,
and clerical personnel support
25
Program ensures adequate and prompt supervision
of residents
26
Opportunity to participate in scholarly
activities such as working on research for
publication or presentation
27
Adequate resources (e.g., sufficient laboratory
space and equipment, computer and statistical
consultation services
28
Perform thorough assessment of patients
29
Develop treatment plans using clinical and
scientific data and patient preferences
30
Use medical knowledge to think through medical
problems
31
Stay current with up-to-date medical knowledge
32
Collaborate and communicate effectively with
patients and their families
33
Work effectively with other health care
professionals
34
Critically appraise evidence about treatment
effectiveness
35
Implement a method to assess the effectiveness of
patient care activities
36
Apply professional and ethical principles to
practice of medicine
37
Respond sensitively to patients culture, age,
gender and disabilities
38
Identify ways delivery systems affect care
quality and patient safety
39
Use system resources to provide cost-conscious
care
40
Hours on duty per week
Busiest rotation in past 6 mos. (4wks)
Previous 4 week rotation
41
Percentage of Residents Responding Yes
42
Take-Home Message

• Residents need to evaluate Faculty
• More summative meetings
• Unfair response to complaints
• Opportunities for Scholarly Activities
• Board Review / Journal Club
• DUTY HOURS !!!

43
Evaluations / Response to Complaints
44
Evaluations

• Improved Evaluations
• 360 Evaluations
• Begin Evaluating Faculty
• Chart Review
• Video Review

45
Response to Complaints

• Gripe Sessions
• ER Call Issues
• Clinic Meetings begin Feb 27th

46
Opportunities for Scholarly Activities
47
Quality Improvement Projects
48
Up-to-Date Evidence

• Academic Afternoon, In-training Exam, Curriculum,
  Rotation Improvements

49
Academic Afternoon

• Curriculum Oversight
• Splinting / Casting workshop
• GXT workshop
• Journal Club
• Morbidity Mortality Conference
• ??? increase to 5pm

50
Proposed Schedule Rough Draft
51
In-training Exam

• Objective measure of your studying
• Objective measure of our teaching
• Benchmark for recruits
• Preparation for ABFM (Board) Exam

52
In-training Exam is NOT

• NOT a reflection on your worth as a person
• NOT an exact surrogate for good clinician, good
  doctor
• NOT the "be-all-and-end-all"
• NOT meant to be punitive

53
In-training Exam Confounders

• Poor test-takers
• English as a second language
• ADHD
• LD in Reading
• Dyslexia

54
In-training Exam Evidence

• lt30 highly correlated to failing Boards

55
In-training Exam Remediation

• Single visit with Center for Teaching and
  Learning Test-Taking Specialists
• more meetings if the recommend.
• Moonlighting suspended 3 months to work on
  Academics
• 12 weekly meetings with an appointed / chosen
  Academic Advisor reviewing questions.
• Retake an exam and pass 10 higher
• Failure Academic Probation

56
Miscellaneous

• Confidentiality
• Subject to Due Process
• NOT being fully-implemented this year but
• parts mandatory
• rest is voluntary

57
Curriculum Improvements

• Family Medicine Activity Directors
• Orientation
• Reading Lists
• Competency

58
Rotation Improvements

• Radiology Dr. Howard Holley
• Urology Dr. Poore
• FamMed Maternity Clinic
• stay tuned.
• and now without further ado what youve all
  been waiting for
• NIGHT FLOAT.

59
Duty Hours

• and the necessity of Night Float!

60
Definition of Duty Hours

• all clinical and academic activities related to
  the residency program
• patient care (both inpatient and outpatient)
• administrative duties relative to patient care
• transfer of patient care
• time spent in-house during call activities
• scheduled activities such as conferences
• NOT reading / off-site preparation

61
80-hour Rule

• Duty hours must be limited to 80 hours per week,
  averaged over a four-week period, inclusive of
  all in-house call activities.

62
1 Day in 7 Rule

• Residents must be provided with 1 day in 7 free
  from all educational and clinical
  responsibilities, averaged over a 4-week period,
  inclusive of call.
• One day is defined as 1 continuous 24-hour period
  free from all clinical, educational, and
  administrative duties.

63
10-hour Rule

• 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.

64
q3 call

• In-house call must occur no more frequently than
  every third night, averaged over a 4-week period.

65
30-hour Rule

• Continuous on-site duty, including in-house call,
  must not exceed 24 consecutive hours.
• Residents may remain on duty for up to 6
  additional hours to participate in didactic
  activities, transfer care of patients, conduct
  outpatient clinics, and maintain continuity of
  medical and surgical care.

66
Post-call Clinics?

• For family medicine programs, the only outpatient
  activity allowed is the scheduled continuity
  office hours in the FMC, and/or self-directed
  activities. No other clinical duties are
  permitted. FM residents may not have continuity
  office hours in the afternoon or evening
  following an overnight call responsibility.
• For programs using a night block rotation,
  residents may have their continuity office hours
  in the FMC either before or after the night block
  hours, as long as there are 10 hours of rest
  between assigned duties and all other duty hour
  rules are addressed

67
Continuity Care for Critical Events

• Admissions
• Obstetrical Care
• should involve all 3 years of residency
• should comply with all duty hour rules

68
Hours on duty per week
Busiest rotation in past 6 mos. (4wks)
Previous 4 week rotation
69
Assumption 1

• 5am start
• 12noon post-call
• 5pm other days
• clinic notes done 7pm
• DUTY HOURS 86.25

70
Assumption 2

• 5am start
• 12noon post-call
• 6pm other days
• or, home 1230 post-call / 530 other days.
• clinic notes done 7pm
• DUTY HOURS 87.75

71
Assumption 3

• 6am start
• 12noon post-call
• 5pm other days
• clinic notes done 7pm
• DUTY HOURS 82
• if 30 min late from hospital 83.5

72
Assumption 4

• 6am start
• 12noon post-call
• 5pm other days
• clinic notes done 5pm
• DUTY HOURS 80

73
YEAH, RIGHT!

• where do we go from here?

74
Current Call Schedule

• 4 (possibly 6) rotations in PGY-1 gt80hrs per week
  / 4 weeks
• Internal Medicine
• Family Medicine
• ObGyn?
• 3 (possibly 4) rotations in PGY-3 gt80hrs per week
  / 4 weeks
• Internal Medicine
• Family Medicine
• ICU?

75
4 Night Float Months

• Adult medicine Intern
• Adult medicine Senior
• Peds/OB Intern
• Peds/OB Senior

76
Where do these months come from?

• Deletes 10 months of q4 call
• Psych moves to PGY-2
• ICU elective (NOT mandatory)
• NO more q4 call for all 36mo!!!

77
What happens when it gets busy?

• or, who is on backup?
• Color-coded primary service teams
• Adult medicine Intern
• Peds/OB Intern
• Senior Backup MIGHT be DNR
• 2 interns in-house
• 2 seniors in-house
• 2 interns on backup
• ??? Adult medicine Senior
• ??? Peds/OB Senior

78
What happens on the weekend?

• Color-coded call teams still exist
• Call on a primary service is now
• Friday pm 12hours
• Sunday am 12 hours
• Saturday 24hours
• Preserves not only weekends off, but other
  beautiful features of color-coded call scheme
• NO more q4 call for all 36mo!!!

79
Yeah, but what about the transition?!

• URGENT (RRC June 2007)
• PGY-3 Archie!!!
• Gita, Pernick, Frannie, Matthew
• PGY-2 Candie Terry! / Jon Roden!
• Allen-Bell, Sartain
• PGY-1 Lee Carter!!!
• Neil Yeager, Dillon Miller
• Richard Dodd!

80
Moonlighting

• some final comments.

81
My Obligation to You

• Because residency education is a full-time
  endeavor, the Program Director must ensure that
  moonlighting does not interfere with the ability
  of the resident to achieve the goals and
  objectives of the educational program.

82
Internal Moonlighting

• Any hours a resident works for compensation at
  the sponsoring institution or any of the
  sponsors primary clinical sites must be
  considered part of the 80-hour weekly limit on
  duty hours.
• This refers to the practice of internal
  moonlighting.

83
Final Comments

• Evaluations
• In-service Exam
• Night Float and Internal Moonlighting