ACGME Task Force Presents New Residency Program Requirements for Public Comment

The Accreditation Council for Graduate Medical Education (ACGME) today presented a set of proposed revisions to Section VI of its Common Program Requirements for public comment over the next 45 days. The Common Program Requirements provide uniform standards for all accredited US residency and fellowship programs that train the next generation of physicians to care for the American public.

In summary, the proposed requirements:

• have an expanded section on patient safety and quality improvement;
• include a new section on physician well-being;
• strengthen expectations around team-based care; and,
• streamline resident clinical and educational work hours to be consistent across the country in a framework that is supported by educators.

"At the core of the proposed standards is the philosophy that residency education must occur in a learning and working environment that fosters excellence in the safety and quality of care delivered to patients today and in the future," said Thomas J. Nasca, MD, MACP, chief executive officer of the ACGME and vice-chair of the Task Force charged with proposing revisions to Section VI. "We recognize that the well-being of physicians is crucial to their ability to deliver the safest, best possible care to patients, and we've thoughtfully constructed enhancements in this area."

Residents and faculty members must consistently work in a well-coordinated team, using shared methodologies to achieve institutional patient safety goals, such as consistent reporting and disclosure of adverse events and unsafe conditions. The proposed requirements continue to emphasize that residents and faculty members need to work in a well-coordinated team, and that supervision is a necessary component of residency training, and allow for customization based on an individual resident’s level of training and ability, as well as patient complexity and acuity.

"Just as drivers learn to drive under supervision in real life, on the road, residents must prepare in real patient care settings for the situations they will encounter after graduation," said Dr. Nasca. "Residents must develop the skills and the confidence to manage challenging situations, under supervision, and must learn to care for patients over extended hours, and during night-time hours, because these are circumstances they will encounter after graduation." In recognition of the significant risk of burnout and depression for physicians, a new section emphasizes the need for both programs and institutions to prioritize physician well-being. Providing policies and programs to support physicians in need, ensuring protected time with patients, and minimizing non-physician obligations are expected to improve both resident education and quality of patient care.

"We all have an obligation to help physicians find meaning and joy in their work, and to provide them with the resources necessary to care for themselves as well as their patients," said Dr. Nasca.

The term "clinical experience and education," hours has replaced the term "duty" hours, in the revised standards. This change underscores that residents'; responsibility to their patients supersedes any duty to the clock or schedule and that hours worked is only one component of providing safe, quality care to patients. The revised standards do not change the total number of clinical and educational hours based on a framework of:

• a maximum of 80 hours per week, averaged over four weeks;
• one day free from clinical experience or education in seven, averaged over four weeks; and,
• in-house call no more frequent than every third night, averaged over four weeks.

After reviewing all of the available research, evidence, testimony, and position of all parties submitting information, the Task Force removed the existing requirement limiting PGY-1 residents to 16 hours of consecutive time on-task, noting a commitment to avoiding disruption of team-based care and to facilitate seamless continuity of care. The limit of consecutive time on-task for all residents is 24 hours plus four hours to manage transitions in care, promoting professionalism, empathy, and commitment. (this is unchanged from the 2011 iteration). Individual specialty Review Committees have the flexibility to modify these requirements to make them more restrictive as appropriate.

"Training to become a practicing physician can be compared to training for a marathon," said Dr. Nasca. "You must learn how to pace yourself, take care of yourself, and recognize your limits. With enough experience comes resilience and the ability to perform under expected, sometimes challenging conditions."

The rationale and context for the proposed requirements are included in a letter to the graduate medical education community from Dr. Nasca.

Background

In the fall of 2015, the ACGME Board of Directors began the periodic review and revision of the Common Program Requirements. The work was divided into two phases. The Phase 1 Task Force focused on Section VI, which addresses professionalism, personal responsibility, and patient safety; transitions of care; alertness management/fatigue mitigation; supervision of residents; clinical responsibilities; teamwork; and clinical experience and education (formerly known as duty hours). Over the last year, the Task Force reviewed the published scientific literature on the impact of standards on the quality and safety of patient care, resident well-being, and resident and fellow clinical care and education hours. It looked at new research from the past five years, including relevant multicenter research trials, as well as position statements from more than 120 organizations and individuals including specialty societies, certifying boards, patient safety organizations, resident unions, and medical student organizations.

In March 2016, a national meeting was convened to allow Task Force members to hear comments from these organizations, experts, and members of the public to inform their deliberations.

Following the 45-day public comment period, the Task Force will review the comments and rationale submitted, and provide a final set of proposed requirements to the ACGME Board of Directors for consideration and approval. Implementation is targeted for the 2017-2018 academic year.

As the next step in the review of the ACGME Common Program Requirements, a Phase 2 Task Force is convening to assess and propose revisions to Sections I-V.