ACGME Standards Effective July 2003
At its February 2003 Board meeting, the Accreditation Council for Graduate Medical Education (ACGME) adopted common program requirements that establish duty hour standards for all ACGME-accredited programs, effective July 2003. In general, the ACGME standards are similar to the New York State regulations, with several key differences. GNYHA has taken particular interest in this issue as New York continues to be the only state in the country that has State-mandated resident working hours limitations. In particular, GNYHA had commented on the ACGME's proposed standards with regard to how those standards would affect New York teaching hospitals and residency programs and attempts to ensure compliance with the State regulations.

Of particular concern to GNYHA was an ACGME requirement that had been proposed in June 2002, stating that "a 10-hour time period for rest and personal activities must be provided between all daily duty periods, and following in-house call." The New York regulations mandate that a resident be provided with a minimum of eight hours off between all working assignments. GNYHA had heard from its members that this more restrictive requirement in the ACGME standard had the potential to compromise efforts to comply with the New York regulations, and had communicated that concern to the ACGME. GNYHA was particularly concerned with the effect that this 10-hour nonworking requirement would have on "night float" systems, which have been identified as a key strategy to ensure compliance with the State regulations.

After some discussion with regard to GNYHA's comments and similar concerns it had heard from other organizations regarding the 10-hour nonworking requirement, the ACGME decided to alter this requirement to say, "[A]dequate time for rest and personal activities must be provided. This should consist of a 10-hour time-off period provided between all-duty periods and after in-house call." For those New York residency programs that have built their compliance efforts around ensuring a minimum of eight hours off between assignments, this change is potentially significant. In the language of the ACGME, "must" is a term used to indicate that something is required, mandatory, or done without fail. In contrast, "should" is a term used to designate requirements that are so important that their absence needs to be justified. What the above change in language is expected to mean to all teaching institutions and residency programs is that if a particular residency program is able to adequately justify a somewhat shorter working assignment separation—such as eight hours—to the relevant residency review committee, then the residency program will not automatically receive a citation from the ACGME on that basis alone.

ACGME Monitoring of the Duty Hours Standards
The ACGME will incorporate monitoring of compliance with its duty hours standards, effective July 2003, as part of its overall accreditation reviews. The duty hours compliance monitoring will be incorporated into the ACGME's usual survey process, through notification to the surveyed residency programs at least 90 days prior to the site visit. Following notification, the residency program is required to complete the ACGME program information form (PIF), and submit it to the ACGME at least 14 days prior to the site visit. Within the PIF, the residency program is expected to address how it has come into compliance with the ACGME duty hours standards. If a residency program is unable to meet a certain requirement (such as the 10-hour nonworking period requirement), the residency program should submit a PIF Addendum, explaining the reasons why it is unable to meet that requirement. Both the PIF and the PIF Addendum are available on the ACGME Web site, at www.acgme.org.

The ACGME will be surveying all residents in a program two months prior to the site visit to assess the program's compliance efforts with the duty hours standards. The ACGME site visitor will then have these results in hand when visiting the program.

NYS Continuing Annual Compliance Surveys
As of October 2002, IPRO had visited all teaching hospitals in the State at least once for the purpose of assessing compliance with the New York regulations regarding working hours and working conditions, and the organization is currently conducting its second set of annual compliance visits to teaching hospitals across the State. According to the New York State Department of Health (DOH), every teaching hospital will be visited again, and the survey teams will focus particular attention on those residency programs that were found to be out of compliance during the first year of compliance reviews or during a complaint investigation. The IPRO survey team will also interview residents within additional programs, such as psychiatry or rehabilitation medicine, on which they did not always focus during the first year, in order to ensure that those residents are not being overworked to compensate for ensuring other compliance efforts.

As GME Central went to press, DOH and IPRO staff were in the midst of reviewing two documents associated with the regulations and survey process. DOH will be releasing a report regarding the first year of the contract that will include aggregate data on hospital compliance and provide more detailed information across specialties. No hospital-specific information, however, will be included in the report. In addition, a comprehensive question-and-answer document is being prepared in response to the many questions that DOH staff and the survey team have been asked regarding the resident working hours regulations and the survey process since the IPRO contract began. That document was developed in addition to the brief question-and-answer document that DOH prepared and distributed several years ago, and a brochure describing the regulations that DOH and IPRO prepared and provided to hospitals for distribution to residency trainees.