ImportanceSince work-hour restrictions were instituted in 2003, sustainably complying with duty-hour regulations remains a challenge for general surgery residency programs across the nation.ObjectiveTo determine whether industry-based process improvement techniques could be leveraged to increase compliance with work-hour restrictions within a general surgery residency.Design, Setting, and ParticipantsThis quality improvement project using Lean methodology was conducted from October to November of the 2021 to 2022 academic year. The setting was a university-based general surgery residency program in southern California with rotations across 5 regional hospitals. The program trains 7 categorical general surgery residents per postgraduate year (PGY) and offers an optional 1 to 3 years for research and career development.InterventionsProgrammatic structures were examined, current and target states were analyzed, opportunities for improvement were identified, root-cause analyses were conducted, and targeted interventions were developed.Main Outcomes and MeasuresResident time logs and annual Accreditation Council for Graduate Medical Education resident and faculty surveys were reviewed from academic years 2019/2020 to 2022/2023. Attending faculty were surveyed on resident preparedness using a 5-point Likert scale. Differences between means and proportions were calculated with corresponding 95% CIs.ResultsThe web-based survey responses of 29 residents (residents per PGY, 7 [PGY1], 14 [PGY2/3], 8 [PGY4/5]; 17 female [54.7%]) were included in this study. Root causes included maxed baseline schedules, late in shift work, culture, service variability, clinical volume, and inefficient workflows. Fifteen multifactorial interventions impacting call and weekend scheduling, work practices and efficiencies, intern and service orientations, and faculty and cultural expectations were implemented. The mean number of residents per block who logged more than 80 hours per week decreased by 3.6 violations per block (95% CI, 2.98-4.22), from 4.4 (12.4%) to 0.8 (2.2%) for a difference of 10.2% (95% CI, 8.4%-16.2%). On the annual resident survey, perceived compliance with 80 hours was 72%, 83%, 83%, and 88%, respectively, over the following study periods: 2019 to 2020, 2020 to 2021, 2021 to 2022, and 2022 to 2023. Faculty perception of resident preparedness for the case increased from a mean (SD) of 2.6 (0.8) to 3.0 (0.5), with a difference of 0.47 (95% CI, −0.52 to 0.68). There were no statistically significant differences in technical skill, clinical judgment, sense of responsibility, efficiency, or sense of well-being.Conclusions and RelevanceResults of this quality improvement study suggest that through Lean methodology, surgical residency programs can improve working environments. This novel approach can increase compliance with resident work hours by engaging front line trainees in the process.

中文翻译：

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利用精益方法提高对工作时间限制的合规性


重要性自 2003 年实施工作时间限制以来，可持续地遵守值班时间规定仍然是全国普通外科住院医师计划面临的挑战。目标确定是否可以利用基于行业的流程改进技术来提高普通外科住院医师对工作时间限制的依从性。设计、设置和参与者这个使用精益方法的质量改进项目于 2021 年至 2022 学年的 10 月至 11 月进行。背景是南加州的一个以大学为基础的普通外科住院医师计划，在 5 家地区医院轮换。该计划每研究生年 （PGY） 培训 7 名分类普通外科住院医师，并提供可选的 1 至 3 年研究和职业发展。干预措施检查了规划结构，分析了当前和目标状态，确定了改进的机会，进行了根本原因分析，并制定了有针对性的干预措施。主要成果和措施从 2019/2020 学年到 2022/2023 学年审查了住院医师时间日志和研究生医学教育住院医师和教师年度认证委员会调查。使用 5 点李克特量表对在职教师的住院医师准备情况进行了调查。结果本研究包括 29 名居民 （每 PGY 居民、7 名 [PGY1]、14 名 [PGY2/3]、8 名 [PGY4/5];17 名女性 [54.7%]）的基于网络的调查回复。根本原因包括基线时间表的最大值、轮班工作延迟、文化、服务可变性、临床量和低效的工作流程。 实施了 15 项影响电话和周末安排、工作实践和效率、实习和服务导向以及教师和文化期望的多因素干预措施。每个街区每周记录超过 80 小时的居民平均人数减少了 3.6 次违规（95% CI，2.98-4.22），从 4.4 （12.4%） 减少到 0.8 （2.2%），差异为 10.2%（95% CI，8.4%-16.2%）。在年度居民调查中，在以下研究期间，对 80 小时的感知依从性分别为 72%、83%、83% 和 88%，分别是 2019 年至 2020 年、2020 年至 2021 年、2021 年至 2022 年和 2022 年至 2023 年。教师对住院医师对病例准备情况的感知平均值 （SD） 从 2.6 （0.8） 增加到 3.0 （0.5），差异为 0.47 （95% CI，-0.52 至 0.68）。在技术技能、临床判断、责任感、效率或幸福感方面没有统计学意义差异。结论和相关性这项质量改进研究的结果表明，通过精益方法，外科住院医师计划可以改善工作环境。这种新颖的方法可以通过让一线实习生参与到这一过程中来提高对居民工作时间的依从性。