Researchers at the University of California San Diego School of Medicine have shown that a systemic approach to eliminating inefficiencies in surgical residency programs can reduce unnecessary work hours in the general residency program at UC San Diego. The approach—based on Lean methodology—can also positively impact the training and overall well-being of surgery residents. The results are published today in the Journal of the American Medical Association (JAMA).
"Our study shows that with dedicated process improvement efforts and sophisticated quality improvement analysis, we can enhance the working environment for surgical trainees and all physicians," said J. Jeffery Reeves, M.D., corresponding author and fellow in the Department of Surgery at UC San Diego School of Medicine. "Our goal is to eliminate unnecessary work for physicians, and this study offers a framework that any institution across the country can use to analyze and improve their systems."
The Accreditation Council for Graduate Medical Education introduced work-hour restrictions for medical trainees more than two decades ago to enhance patient safety and resident well-being, and the restrictions have proven effective for their stated goals. This study focused on determining whether Lean methodology—a broad set of principles and tools designed to increase value by eliminating waste—could effectively support surgery residents in adhering to 80-hour-per-week work restrictions. Many residency programs continue to struggle with implementing hour restrictions.
The researchers conducted a quality improvement project using a hybrid Lean process improvement workshop, identifying systemic inefficiencies and implementing targeted interventions. The project was conducted at UC San Diego Health. It included three Kaizen events—focused workshops that reviewed issues and clearly defined the problems before developing solutions. These workshops included the program director, associate program directors and resident representatives from each post-graduate year. The application of Lean methodology allowed the team to identify areas for improvement, emphasizing data analysis and understanding the motivation of surgical residents.
The results showed that the average number of surgical residents exceeding the 80-hour per week limit significantly decreased after the interventions from 4.4 (12.4%) to 0.8 (2.2%) for a difference of 10.2%. Additionally, the faculty's perception of resident preparedness improved, with no significant changes in technical skill, clinical judgment, or sense of responsibility.
Implementing the Lean process faced initial challenges, such as concerns that reducing resident hours might increase the burden on faculty. However, the analysis revealed that changes targeting redundant processes improved overall efficiency without impacting patient care or increasing faculty workload. The team also emphasized the importance of a cultural shift, encouraging residents to prioritize their well-being to be more present and energized for their patients.
"Lean methodology was crucial in implementing new processes that ensure compliance with work-hour requirements," said Garth Jacobsen, M.D., clinical professor and program director of the general surgery residency program at the UC San Diego School of Medicine Department of Surgery and interim chief of the Division of Minimally Invasive Surgery at UC San Diego Health. "We aim to create solutions that have long-term staying power by addressing problems holistically, and this study demonstrates that approach's success."
The study highlights the potential of Lean methodology to support compliance and resident well-being while addressing the cultural expectation of extended work hours. Structured, step-by-step improvements using Lean methodology can reduce unnecessary work hours for surgical residents. By systematically assessing the current situation and developing targeted interventions, UC San Diego Health reduced the number of hours residents spend in the hospital, giving them more time for studying and preparation.
"Many surgical departments nationwide face similar challenges," said Brian Clary, M.D., M.B.A., the study's senior author and chair of the Department of Surgery at UC San Diego School of Medicine. "By following the framework outlined in our study, other residency programs can replicate our success and uncover opportunities specific to their needs."
The study serves as a model for other graduate medical education programs, emphasizing that a structured approach can ensure compliance with work-hour policies across all UC San Diego residency programs. By minimizing unnecessary work, the institution demonstrates its commitment to supporting health care providers while delivering efficient, high-quality patient care. This framework offers a cost-effective solution to optimize both resident and institutional outcomes.
Co-authors include: Nicole Goldhaber, Hannah Hollandsworth, Kristin Cox, Ana Maria Dumitru, Christopher A. Longhurst, Jennifer Berumen, and Allison E. Berndtson from UC San Diego, and Beiqun Zhao from the University of San Francisco.
