One of the mantras of performance improvement is that caregivers and provider organizations should learn from their experiences. That’s all well and good, but how about policy-setting organizations?
A few moments ago in the on-line version of the New England Journal of Medicine, two of the Biggest Kahunas in the safety and quality worlds – the Joint Commission (TJC) and the Accreditation Council for Graduate Medical Education (ACGME) – announced bold new policies. To their credit, both organizations have learned from their experiences… and their mistakes.
Let’s start with the Joint Commission. In a gutsy move, three TJC leaders (led by CEO Mark Chassin) call for raising the bar on measures whose purpose is public accountability (i.e., measures used for pay for performance or public reporting programs). Mark was nice enough to invite me to co-author the manuscript, and I was proud to do so. I think it’s an important statement.
We begin today’s article by tracing the surprisingly brief history of national quality measurement. “Over the past decade we have learned that standardized data can be collected by thousands of hospitals to identify and implement substantial improvements in care,” we write. “We believe that the ‘proof of concept’ phase of national quality measurement and public reporting has now been completed.”
But, while quality measurement has led to real progress, there have been several speed bumps along the way – particularly when flawed measures have become national standards. To move the field forward, we propose that any measure being used for accountability purposes must:
- …be based on a strong research foundation (at least two studies using robust methods, often randomized trials);
- …capture whether the evidence-based care has actually been delivered; (“Organizations that wish to improve their performance record [on things like smoking cessation or discharge counseling] may be tempted to create clever… forms with just the right check-boxes… to satisfy the chart reviewers rules, instead of doing the hard work of improving their clinical care,” we observe);
- …address a process relatively proximate to the desired outcome; and
- …have minimal or no adverse consequences.
We then point to six existing TJC/Medicare measures that do not stack up, including measures of smoking cessation counseling and discharge instructions (which fail to capture the care process of interest and are subject to gaming); the measure of LV systolic function in hospitalized patients with heart failure (not proximate enough to an outcome of interest); and the measure of door-to-antibiotics time for patients with pneumonia (unanticipated consequence of unnecessary antibiotics for patients who don’t actually have pneumonia).
On the glass-is-half-full side of the ledger, of the 28 core measures publicly reported in 2010 by TJC and Medicare, 22 of them do meet all four criteria. Reassuringly, since the advent of public reporting, we’ve seen striking improvement in performance on these measures: whereas only 20% of US hospitals nailed more than 90% of all 22 measures in 2002, nearly 71% did so in 2008.
While the NEJM article describes a new philosophy around quality measurement, this is not just an academic exercise. In today’s issue of the Joint Commission’s online newsletter, TJC announced that it would embrace this approach for all its present and future quality and safety measures, and it challenged other stakeholders to do the same. Bravo.
We concluded our article this way:
Let’s turn now to the ACGME, which today released its long-awaited revised residency duty hour regulations (they are subject to public comment for about 6 weeks before they become the Law of the Land). You know the background: in 2003, the organization famously made the “80-hour work week” a medical term of art. (I recently met Bertrand Bell, whose “Bell Commission” originally crafted New York state’s 80-hour limits following the death of Libby Zion. “How did you choose 80?” I asked the curmudgeonly Dr. Bell, now in his 80s. “Sixty seemed too little, and 100 seemed too much,” he told me. “So we split the difference.”)
In their article in today’s NEJM, ACGME leaders, led by CEO Tom Nasca, chronicle the positive changes that the 2003 regs were supposed to usher in, and why so many of them failed to materialize. For example, concerns have been raised that the regulations created a shift-work mentality among residents, have overemphasized duty hours over the equally important issue of housestaff supervision, and failed to account for the maturation stages of residents as they move through their years of training. Most damning, while there is evidence that residents’ quality of life improved after the 2003 duty hours limits, there is no evidence that the regulations resulted in better quality or safety.
In light of continued national anxiety about patient safety, some fairly aggressive recommendations in a 2008 IOM report, the fact that most other industrialized countries have duty hour limits of 50-60 hours/week, and substantial push from sleep researchers and other experts, the betting was that the ACGME would slash the duty hours limits again. For the last several months, the buzz among residency directors and teaching hospital leaders has crescendoed – like a World Cup crowd armed with noisy Vuvuzelas. Might the number of duty hours indeed be cut, perhaps down to as few as 60?
Cue the drum roll…..
And the answer is: the duty hour limits will remain 80 per week.
Yet the new regulations do call for substantial changes. For example, they:
- Insist on direct, in-house attending-level supervision of interns (either at the bedside or “on site and available to provide direct supervision”)
- Allow housestaff workload and autonomy to escalate as residents become more senior.
- Promote the primacy of education over service in curricular decision-making.
- Forbid 30-hour shifts for interns; the maximum intern shift will now be 16 hours (more senior residents can still do overnight shifts of up to 28 hours, with “strategic napping” encouraged).
I’m pleased that the ACGME resisted the pressure to cut the weekly duty hours further. In addition to the massive costs of replacing resident labor (with hospitalists or allied health professionals), I believe that lower hours would be detrimental to training: residents would be forced to pack more work into less time, shorter hours would further promote a run-for-the-doors mentality, we’d be stuck with even more risky handoffs, and – I know I sound like an old fogey – I worry that even good residency programs are graduating residents who aren’t ready to be practicing doctors because they haven’t cared for enough patients, exercised enough autonomy, or developed their professional compass around when it is in their patient’s interest for their physician to work while tired.
By retaining the 80-hour work week, I’m guessing that the ACGME hopes to give programs and hospitals some breathing room to focus on some of the more challenging, but ultimately more important, issues, including how to promote a culture of safety among residents and their programs, how to enhance supervision of trainees early in their training cycle while allowing graduated autonomy as residents move up the food chain, and how to emphasize education over service in resident rotations.
At UCSF Medical Center, anticipating the need for around-the-clock supervision and a ban on 24-hour shifts (we predicted that they would be forbidden for all trainees, not just interns), we will launch overnight hospitalist attending coverage starting next week. Although it will take a few organizational back flips to comply with the new intern 16-hour limits, today’s ACGME announcement means that the amount of transformation and associated costs will be significantly less than we anticipated. I’m hoping that we – and teaching hospitals everywhere – take advantage of this break by focusing some of our energy and resources on relieving housestaff of many of their clerical tasks that soak up their limited hours, rebalancing rotations to emphasize education over service, and improving handoffs. I think these moves would honor the spirit of what the ACGME intended to do.
Kudos to Tom Nasca and the ACGME for not taking the easy path: cutting duty hours to give the appearance of acting decisively in the name of safety. While one might arguably improve safety in the short term by slashing resident hours and replacing trainees with senior faculty (assuming we could find, and afford, enough of the latter), we would ultimately pay the price in safety and quality as a generation of undertrained individuals grew up to become our future physician workforce. The ACGME’s choices reflect an appropriate balancing of safety today and safety tomorrow, which is as it should be.
Taken together, both of today’s announcements are the products of courageous executives helping their organizations to make hard choices – choices that will be controversial but strike me as well considered and generally wise. As important as the individual decisions, both Chassin and Nasca have demonstrated that – even as they require that their accredited hospitals and training programs engage in continuous improvement and learn from their mistakes – they are guiding their own organizations to do the same.