Reducing Violations to the 80-hour Work Rule with Electronic Health Record to Establish Rapid Culture Change, Does It Work?

Abstract

Objectives: In our free-standing general surgery residency program, it was noted over the past decade that we had an exorbitant number of resident work hours violations. This resulted in multiple citations from the Accreditation Council for Graduate Medical Education (ACGME) with subsequent probation. To restore accreditation requirements and provide trainees with a balanced learning environment, work hours were restructured. Reporting of work hours in the residency management software was authenticated by the organizational Electronic Health Record (EHR). This quality improvement project evaluated the effectiveness of compliance to the 80-hour work rules in a single rural surgical training residency program with the aid of EHR. Methods: The hours are actively monitored in the residency management software, New-Innovations (NI) and cumulative weekly reports were created. With the design, residents were scheduled to work a maximum of 13 hours per day beginning at 0600 and operating room (OR) time concluding by 1700. During each 4-week rotation, residents were assigned one Friday call, one Saturday call and four hours of transitional call. The primary outcome of this project was the number of resident violations to the 80 hours rule before and after implementation of those measures. The secondary outcomes were the residents’ comparative academic and clinical performances. This project also evaluated the overall cultural change and satisfaction with the program using ACGME survey data. Results: Compared with the non EHR era (2013-2015), the number of violations during the EHR era decreased significantly. (Mean non EHR= 167.3, EHR = 24.6) (p =0.0009) Case volumes and board pass rates were a central focus throughout the changes. No decrease in operative volume was noted for graduating residents (N = 8, non EHR= 1,062, Mean EHR = 1,110) (p = 0.5). Over the three years since the changes, the board pass rates have improved from 64% to 80% in Certifying Examination (CE) (N = 8, Passing % non EHR = 64%, EHR = 80%) (p = 0.03) Qualifying Examination (QE) (N = 8, Passing % non EHR = 100%, EHR = 93%) (p =0.1). Conclusion: Reduction in work hour violations can be achieved with a reliable schedule, promotion of accurate reporting by residents, and monitoring through EHR reports. Adherence to work hour guidelines is essential for resident well-being and a healthy and conducive clinical learning environment without diminishing operative experience.