Introduction: Since the ACGME first instituted duty hours restrictions in 2003, surgery training programs have faced challenges balancing resident wellbeing, quality of education, and quality of patient care. Despite prioritization and significant effort, our general surgery residency continues to be challenged with compliance related to the 80-hour work week. We sought to explore whether sophisticated quality and process improvement techniques borrowed from industry could be successfully applied to this complex problem in an effort to improve resident well-being and compliance.
Methods: Lean process improvement methodology was applied to examine the structure of our program, identify best practices in scheduling and day-to-day workflows, uncover variations and opportunities for improvement, and develop targeted countermeasures.
The team reviewed our work hour reporting system, work hours logged, work hour violation occurrences, reasons listed for violations, surgical case volumes and staffing resources on each surgical rotation.
The daily workflow and call schedules for interns, juniors, and senior/chief residents were outlined in a detailed stepwise approach. Pain points and barriers to complying with work hour rules were identified. A resident survey was administered to prioritize which issues had the greatest impact on prolonged work hours or unhealthy working environment. A root cause analysis for each major contributor to non-compliance was conducted. A PICK chart was used to prioritize identified opportunities to improve.
Countermeasures were developed and implemented. Our prospective measurement plan included monthly duty hour logs, monthly rotation evaluations, yearly ACGME survey, and a faculty survey on resident preparedness.
Results: Thirty-six improvement opportunities were identified. Root causes included a tendency to schedule a near-maximum amount of hours, new patient consults that come late in a shift, variability in resident and attending expectations, clinical volume, inefficient workflows, and a culture of work over self. In response to identified issues, there were 15 actionable items.
Figure 1 demonstrates improvement in duty hour violations since implementation of proposed countermeasures.
Conclusions: Lean process improvement methodology can be applied to complex challenges present in our educational programs. Such an approach led to a significant reduction in work hours and a sustained improvement in duty hour compliance. We are currenty exploring similar methods to address additional challenges in our educational programs.
