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Invited Commentaries

Elevating Resident Voices in Health Systems Change: Lessons From the Closure of Hahnemann University Hospital

Nasca, Thomas J. MD; Johnson, Paul Foster MFA; Weiss, Kevin B. MD, MPH; Brigham, Timothy P. MDiv, PhD

Author Information
doi: 10.1097/ACM.0000000000003146
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Abstract

Following press reports of financial troubles in spring 2019,1,2 Hahnemann University Hospital (HUH) announced its closure on June 26, 2019, resulting in a catastrophic loss for Philadelphia and the teaching hospital’s patients, employees, faculty, and residents and fellows. An important local and regional source of care was about to vanish, and a mainstay of medical education for more than 120 years was preparing to close its doors.3 The closure’s magnitude was matched by its speed. More than 550 residents and fellows, some of whom had recently relocated to Philadelphia to start their postgraduate journey, were informed that their programs would cease to exist by early August. In this Invited Commentary, the authors describe the roles of the ACGME and other organizations in responding to the closure, and they examine the need to elevate resident and fellow perspectives in regulatory processes and policies addressing substantial disruptions to graduate medical education (GME).

Fact-Finding Visit at HUH

On July 12, 2019, a team of 11 senior staff members of the Accreditation Council for Graduate Medical Education (ACGME) conducted a fact-finding visit at HUH. The ACGME’s visit was intended to inform a course of action for its accreditation of 35 HUH GME programs, as well as to explore how the ACGME could assist the hundreds of residents and fellows who would soon be displaced. The ACGME requires institutional sponsors of GME to maintain policies that support ACGME-accredited programs and their residents and fellows when patient care is interrupted and when institutional sponsors and/or their programs close.4 The visit provided an opportunity to observe HUH’s efforts to comply with these requirements.

Before the visit, the ACGME had begun to assist HUH residents and fellows in identifying positions in programs where they could continue their education. The ACGME provided a database with daily updates of available transfer positions for HUH residents and fellows, organizing a flood of assistance from 190 sponsoring institutions in 39 states that offered a total of 1,530 positions. For the fact-finding visit, the ACGME team traveled to HUH to listen and respond to first-hand information from residents, fellows, program directors, the designated institutional official, and HUH’s executive leaders. The ACGME needed to hear the voices of those affected by the loss of HUH to respond appropriately to the rapidly unfolding crisis.

While such a visit may appear to be an unusual step for the ACGME as an accreditor, it was consistent with past ACGME responses to events resulting in substantial disruption to GME. When Hurricane Katrina devastated New Orleans and the Gulf Coast in 2005, a number of residency and fellowship programs ceased to function. At that time, the ACGME assisted residents and fellows by facilitating temporary and permanent transfers to other programs. The experience of GME disruption after Katrina resulted in the ACGME’s adoption of an “extraordinary circumstances” policy in response to events “that significantly alter the ability of a sponsor and its programs to support resident education.”5 This policy created a structure for communication that enables the ACGME to work closely with sponsoring institutions and programs when resident or fellow education must be reconstituted or restructured.

Recently, the ACGME has used fact-finding visits to understand the realities and concerns of residents, fellows, faculty members, and GME leaders in times of crisis. For instance, in 2017, ACGME staff members visited the 12 sponsoring institutions located in Puerto Rico to learn how the island’s GME community responded to the destruction wrought by Hurricanes Irma and Maria. While no GME programs in Puerto Rico closed as a result of the hurricanes, the visits provided a direct line of communication between the ACGME and residents, fellows, and others that conveyed important information about local conditions and experiences.

The fact-finding approach again demonstrated its usefulness in 2019 in assisting a GME community disrupted by a corporate bankruptcy. During the visit to HUH, the ACGME team spoke with hundreds of residents and fellows and all program directors. The team found that residents, fellows, and program directors alike considered their voices to have been ignored in decision making and deemed themselves “out of the loop” of important information that would affect their career transitions. ACGME policies and procedures were part of a complex regulatory environment that had just become palpable to many. In particular, residents, fellows, and program directors were abruptly introduced to bankruptcy court processes and to a set of GME financing rules established by the Centers for Medicare and Medicaid Services (CMS) that governed cap adjustments for the transfer of reimbursement for residency positions to programs accepting the HUH residents for transfer. In most cases, acceptance by other programs was contingent on the terms of such cap adjustments, and residents and fellows expressed a need for assistance in developing a working knowledge of this process. In the meetings, residents and fellows were strong advocates for themselves and their colleagues, and they provided important feedback about the difficulties they faced.

Assistance to HUH’s Residents and Fellows

Using feedback from the HUH visit, the ACGME refined its processes for assisting residents and fellows in identifying potential transfer positions, and it enhanced its communication with the GME community at HUH as well as other sponsoring institutions and programs, CMS, and the public. Information from the visit also informed the ACGME’s comments and responses on behalf of residents and fellows in the bankruptcy court proceedings in July 2019.

While it was essential for the ACGME to learn as much as possible about resident and fellow concerns, not all of these concerns could be considered actionable by an accreditor. For example, some residents and fellows who expected to relocate outside of Philadelphia risked forfeiting large deposits on rental housing. Others suddenly and urgently needed to move their entire families to the sometimes far-away locations of their new programs. While the ACGME was able to identify and publicize resources relevant to some of the residents’ challenges, any direct intervention in some matters would have been well outside conventional expectations of the ACGME’s role.

Despite these limitations, the ACGME participated in HUH’s bankruptcy proceedings by joining the Educational Commission for Foreign Medical Graduates (ECFMG) and the Association of American Medical Colleges (AAMC) in support of implementing HUH’s program closure and reduction policy, which stipulated that HUH would work within CMS regulations to direct funding toward completion of the residents’ education. The ACGME position database served as a vital mechanism for programs and sponsoring institutions to connect with HUH’s residents and fellows, facilitating the transfer of all displaced residents and fellows to new programs within 6 weeks.

The ACGME also joined other organizations in addressing specific concerns of the HUH residents and fellows. The ECFMG assisted residents and fellows with J-1 visas as they moved to new programs. The ACGME supported the AAMC and ECFMG as the organizations filed responses in bankruptcy court to support solutions to resident and fellow issues, such as securing professional liability insurance coverage after the termination of HUH’s policy. The American Osteopathic Association assisted HUH residents with its requirements and those of Pennsylvania’s State Board of Osteopathic Medicine. The American Medical Association raised funds to defray residents’ relocation costs. The Federal Credentials Verification Service of the Federation of State Medical Boards accepted HUH’s educational records to accommodate future primary source verification requests.

Resident and Fellow Interests

While the ACGME worked with these and other organizations and government agencies to coordinate assistance, it was evident that residents and fellows were vulnerable to negative consequences of HUH’s closure that could not be mitigated by the ACGME’s best efforts. It was impossible for any single organization to represent all the interests of residents and fellows or for any organization to represent resident and fellow interests to the exclusion of other stakeholder interests.

The exact limits of the ACGME’s advocacy for residents and fellows have long been questioned. The ACGME Institutional Requirements approved in 1998 included new standards that were intended to protect residents in their learning environments under the principle that such protections should be extended to residents as students.6 Shortly thereafter, the National Labor Relations Board (NLRB) ruled that residents were employees under the National Labor Relations Act.7 The NLRB decision acknowledged that employed residents are also learners, and the ACGME continues to enforce requirements related to the conditions of resident appointments and the quality of clinical learning environments. The AAMC and others have argued in the past that the ACGME, through the leverage of accreditation and requirements, is well positioned to effectively address residents’ educational and workplace issues, such as the assignment of excessive noneducational service, workplace safety, and well-being.8,9

The ACGME accreditation model is primarily one of professional self-regulation that must prioritize the public interest,10 and it is in that interest that the ACGME promotes the well-being of residents and fellows. Over time, the ACGME has added to the protections that sponsoring institutions and programs must guarantee for residents and fellows in recognition of their needs as both workers and learners. New Institutional and Common Program Requirements, such as those related to resident and fellow well-being, have attempted to codify new norms for learning and working environments.4,11 The ACGME has also supplemented its accreditation activities with formative evaluation approaches designed to stimulate improvement (e.g., the Clinical Learning Environment Review Program12), explicitly linking the quality of resident and fellow learning with the quality of clinical learning environments.

Throughout this evolution, the ACGME has continued to emphasize its responsibility to the public while protecting the interests of residents and fellows through its accreditation process. In the circumstances surrounding HUH’s closure, the public and resident interests were largely aligned, which facilitated the ACGME’s efforts to provide assistance. However, while the ACGME has sought to amplify and respond to resident and fellow perspectives, it has not pretended to represent the voices of the residents and fellows themselves.

Elevating Resident and Fellow Voices

It has been observed that HUH’s closure is emblematic of the moral and ethical dilemmas associated with the rapidly changing U.S. health care environment. Residents and fellows, who are navigating their professional journey through this rapidly changing landscape, should have a proper voice in the development of regulations and policies that speak to these new challenges.

Currently, residents and fellows serve as full members on all ACGME Review Committees and the ACGME Board of Directors. The resident members advise the ACGME through the Council of Review Committee Residents. In light of the HUH experience, the ACGME will seek resident input to enhance the ACGME’s efforts to support resident and fellow well-being in extraordinary circumstances such as a teaching hospital’s rapid closure. The ACGME Board of Directors has begun a process to identify tools to respond to similar circumstances. In 2020, the ACGME will collaborate with other organizations to identify additional mechanisms for residents and fellows to participate in the medical profession’s discourse on how to manage future disruption to GME that results from dynamic forces in the health care market and turbulence in health care systems.

Residents and fellows represent a unique public asset in these challenging times. Recognizing that residents and fellows are the future of the medical profession and the future of health care, the ACGME will continue to look for new ways to integrate their perspectives when addressing disruptions to GME and related accreditation and policy issues that affect their education, their daily lives, and their professional futures. HUH’s closure has started an important conversation about health care and GME, and resident and fellow contributions to this discourse demand attention.

Acknowledgments:

The authors acknowledge the assistance provided by ACGME staff and Review Committee members who facilitated the transfer of residents and fellows displaced from Hahnemann University Hospital and by the hundreds of sponsoring institutions and programs that offered positions to those residents and fellows.

References

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