Assuring Quality Patient Care and Quality Education

William W. Pinsky

The Ochsner Clinic Foundation is committed to high-quality graduate medical education (GME) in an environment that creates proper balance between education and patient care. As mentioned in this column previously, the challenges we have recognized as barriers to this commitment include shortened length of hospital stays, increased emphasis on ambulatory care, reduction in support staff, and the increased acuity of hospitalized patients. At Ochsner, we have continually attempted to improve the fundamental aspects that provide superlative education and maintain the quality of our house staff's lives.

In October of this year, the Association of American Medical Colleges (AAMC) published the AAMC Policy Guidance in Graduate Medical Education for institutions sponsoring GME programs. With this guidance, the AAMC pledges strong support for the Accreditation Council for Graduate Medical Education (ACGME) in its effort to improve the quality of GME in the United States. The four essential components to this guidance policy are highlighted here.

Institutional Oversight and Program Support

Institutional sponsors of GME should exercise strong common centralized oversight for all their GME programs.
Institutional sponsors of GME should authorize a single individual at a sufficiently high level in the organization to take over all the responsibility for the quality of all GME programs.
The institution's governing board should have explicit mechanisms for monitoring the institution's GME activities.
The institutional sponsors of individual residency programs should have written policies and established procedures specifying the level of supervision attending physicians are required to exercise over residents.
Institutional resources must be adequate to create and sustain the safe and supportive learning environments.

The Educational Program

Resident physicians must have opportunities to participate, under supervision, in patient care activities to achieve the competencies required by their discipline.
Resident physicians must have opportunities to exercise, under supervision, greater progressive responsibilities for the care of their patients.
Resident physicians must have opportunities to participate in required conferences, seminars, and other non-patient care learning experiences.
Appropriate, specialty-specific assessment methodologies must be used to document attainment of the knowledge, skills, attitudes, and behaviors required for practice.

Supervision of Residents in Patient Care

The faculty physician of record is responsible for the quality of all the clinical care services provided to patients.
All clinical services provided by resident physicians must be supervised appropriately.
Individual residency programs should have written guidelines governing supervision of residents.
Program faculty directly responsible for the supervision of patient care services provided by resident physicians must be available to participate in that care as if the residents were not involved.
Program faculty are responsible for determining when the resident physician is unable to function at the level required to provide safe, high-quality care to assigned patients.

Resident Duty Hours

Institutional sponsors and individual residency programs should have written guidelines governing resident duty hours.
In no case should residents be scheduled to be on duty more than the hours specified by their training program resident review committee.
If moonlighting is authorized, time spent doing so should be included within the parent program's duty hour limits.
Residents should not be required to have overnight on call duty more frequently than 1 night in 3 as averaged over a month.
Residents should have at least 24 consecutive hours free of all assigned duty every 7 days.
The on-duty time residents spend delivering patient care service of marginal or no educational value should be minimized.

It is my belief that the AAMC policy statements are practical and overall support the ACGME in their attempt to set appropriate standards. The Ochsner Clinic Foundation pledges to support these policies in the spirit necessary to assure the continuation of quality GME programs in an environment conducive to both learning and providing quality patient care.