Enhancing Hospital Efficiency and Patient Outcomes Through Flexible Resident Scheduling: A Meta-Analysis

Progressing technological demands of advanced reactor development require that the designer have at his disposal quick-responding analytical support as well as immediate access to experimental facilities. The close cooperation between design office, research and development department, and trial manufacturing provides the necessary short iteration loops when developing new methods and products. Over the last two decades, many research programs were directed at solving specific problems with steam generators and heat exchangers, or improving known procedures. From various recent materials, fabrication, and performance tests, a few examples are selected and briefly described. These include bimetallic welds, creep fatigue, surface protection, fabrication tests for large helical bundles, gas mixing, flow-induced vibrations, and sodium technology.

Resident work hours have been a recurring source of concern and controversy for many years. From the Spartan origins of the Halsted generic model of the surgical service at Johns Hopkins in 1897 to the present, there have been major tensions between the educational needs of learners and the workload demands of patient care, resulting, at times, in classic labor-management confrontations about work hours and conditions.

Received from the Anesthesia Service, VA Palo Alto Health Care System, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California; the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; and the Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.HEALTHCARE delivery takes place 24 h a day, 7 days a week, and is colloquially termed a “24/7” operation. Anesthesia providers are required to deliver critical around-the-clock care to a variety of patients. This parallels the situation in many other domains that provide such services, e.g ., transportation, law enforcement, communications, fire fighting, technology, manufacturing, and the military. Even “convenience” industries (e.g ., gas stations and grocery stores) now provide uninterrupted access. These continuous operational demands present unique physiologic challenges to the humans who are called on to provide safe operations within these systems. Human physiologic design dictates circadian patterns of alertness and performance and includes a vital need for sleep. Human requirements for sleep and a stable circadian clock can be, and often are, in direct opposition to the societal demand for continuous operations.Recently, patient safety has taken center stage in health care. The Institute of Medicine's report “To Err Is Human: Building a Safer Health System,” revealed that medical errors contribute to many hospital deaths and serious adverse events. 1The response to this report was widespread and included the Quality Interagency Coordination Task Force's response to the President of the United States, “Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.”∥2This report listed more than 100 action items to be undertaken by federal agencies to improve quality and reduce medical errors. One action promised by the Agency for Healthcare Research and Quality was “the development and dissemination of evidence-based, best safety practices to provider organizations.” In addition to the multiple recommendations to improve patient safety, the report from the Agency for Healthcare Research and Quality included a review chapter on sleep, fatigue, #and medical errors. **There is evidence that the issue of fatigue in health care is coming to prominence on a national level. In April 2001, Public Citizen (a consumer and health advocacy group) and a consortium of interested parties petitioned the Occupational Safety and Health Administration to implement new regulations on resident work hours (table 1). The primary intent of the regulations is to provide more humane working conditions, which the petitioners declare will result in a better standard of care for all patients. Also, the Patient and Physician Safety and Protection Act of 2001, which would limit resident physician work hours, was introduced in Congress. Recently, the Accreditation Council on Graduate Medical Education, the accrediting organization for residency training programs in the United States, has approved common program requirements for resident duty and rest hours that will take effect in July 2003. ††The potential impact of sleep loss and fatigue, specifically among anesthesiologists, has received only sporadic attention. 3,4The cognitive demands of intraoperative patient care requires an iteration of data collection, evaluation of its relevance to patient status, development and implementation of plans to maintain the desired patient status, and monitoring the outcome of interventions. These complex tasks require sustained attention or “vigilance” and are particularly vulnerable to the effects of fatigue. 5–8The purpose of this article is to review the physiology of prolonged work cycles and fatigue, to relate this to the work milieu of the practice of anesthesiology, and suggest economically feasible recommendations to mitigate the effects of fatigue.Sleep loss and disruption of circadian rhythm that result from arduous work schedules can lead to reduced safety, performance, and health. While some of these outcomes are well documented, much remains to be learned about the short- and long-term effects of sleep and circadian disruption. The following nonmedical examples of the safety, performance, and health risks associated with around-the-clock operations illustrate the increasing human and economic costs related to ignoring the effects of these physiologic disruptions.There have been several high-profile accidents where fatigue was identified as either causal or contributory. For example, although alcohol is often cited as the central reason in the Exxon Valdez marine grounding, the National Transportation Safety Board investigation identified fatigue as one of the probable causes of the accident. 9Similarly, circadian factors were identified as contributing to the errors that resulted in the nuclear accidents at Three Mile Island and Chernobyl. 10,11Fatigue resulting from the work–rest patterns of managers was also acknowledged as an important component of the flawed decision-making that contributed to the space shuttle Challenger accident. 12Fatigue-related accidents have been identified in every mode of transportation and can be found in many around-the-clock operational settings. Clearly, there are a variety of adverse outcomes such as economic costs, disrupted service, injuries, and even fatalities that result from these accidents. For example, the Exxon Valdez grounding was associated with environmental cleanup operations and legal cases involving billions of dollars, and Space Shuttle operations were suspended for several years after the Challenger disaster.Fatigue-related safety risks affect us at both individual and societal levels. A recent poll by the National Sleep Foundation indicated that one of two drivers reported having driven while drowsy in the past year, ‡‡and one of five acknowledged having “nodded off” while driving. Fatigue contributes to 100,000 crashes annually that result in 76,000 injuries and 1,550 fatalities, according to estimates by the National Highway Traffic Safety Administration. 13Recently, an international group of scientists estimated that fatigue is causal in 15–20% of all transportation accidents, that official statistics underestimate the scope of the problem, and that fatigue exceeds the combined contribution of alcohol and drugs in transportation accidents. 14Fatigue caused by sleep loss and circadian disruption can degrade performance and reduce many aspects of human capability. 15Known performance effects include reduced attention–vigilance, impaired memory and decision-making, prolonged reaction time, and disrupted communications. 16–20These degraded performance outcomes create a situation where there is increased risk for the occurrence of errors, critical incidents, and accidents. 15Fatigue also creates increased performance variability, with cyclic reductions in alertness and performance. 21Fatigued workers have a tendency to slow down work processes to maintain accuracy, a classic effect known as the speed-accuracy trade-off. 22It takes only a moment of reduced performance during a critical task to have a negative outcome. Even if a lapse in performance occurs during a noncritical task, the system vulnerability shifts to a less safe state.Fatigue-related accidents are sometimes considered to be a result of falling asleep. Performance gaps can be the result of these “microsleeps,” which are brief, uncontrolled, and spontaneous episodes of physiologic sleep. 8There can be significant performance reductions that are sufficient to create safety risks prior to and immediately after the occurrence of a microsleep. 23,24Slowed cognitive throughput, reduced memory, slowed reaction time, lowered optimal responding, and attention lapses can create an increased opportunity for errors to occur. 25Consider the circumstance where an anesthesiologist's response to an alarm is slowed and an inappropriate decision guides an incorrect action. The practitioner may have been “awake,” but fatigue-related performance decrements could be contributory to the occurrence of any error, incident, or accident that resulted from the action.The decrement in psychomotor performance resulting from sleep deprivation have been correlated with those resulting from the impairments associated with ethanol ingestion. 26Performance on a hand–eye tracking task declined such that the impairment was equivalent to a blood alcohol level of 0.05% after 17 h of wakefulness. At 24 h of sustained wakefulness, the impairment in psychomotor function was equivalent to a blood alcohol concentration of 0.1%, at or above the legal limit for driving in most states. These data could be useful to help quantify fatigue-related effects with a drug that the public and policy makers better understand.Specific clinical skills of importance to the practice of anesthesiology deteriorate as a result of fatigue. On a simulated monitoring task where subjects were asked to monitor and record the time of significant deviation of clinical variables (e.g ., heart rate, blood pressure), Denisco et al . reported lower “vigilance scores” in the group that had been on call. 27The ability to interpret electrocardiographic changes and to do simple mathematical calculations is compromised among sleep-deprived house officers. 28The speed and quality of intubation was diminished among emergency department physicians working the night shift as compared with their performance while working during the day. 29,30Many of the fatigue-related decrements in performance identified in residents are potentially worse in older physicians. Aging is associated with a tendency toward early awakening, an exaggerated dip in arousal midafternoon, and a decreased tolerance of late-night and shift work. 31The unique demands of night call on older anesthesiologists are more onerous than those found in other specialties. 32Among recently retired anesthesiologists, night call was identified as the most stressful aspect of anesthetic practice and the most important reason for retirement. 33,34Beyond the safety risks and performance decrements associated with sleep loss and circadian disruption, there are a variety of personal health concerns. Several studies have shown that long-term exposure to shift work represents an independent risk factor for the development of both gastrointestinal and cardiovascular diseases. 35–39A recent study found that women working the night shift had a 60% greater risk for breast cancer compared with women who never worked the late shift. 40There is evidence that some adverse pregnancy outcomes are related to working conditions. 41A meta-analysis of 29 studies, including more than 160,000 women, evaluated the association of physically demanding work, prolonged standing, long work hours, and cumulative “fatigue score” with preterm delivery, pregnancy-induced hypertension, and small-for-gestational-age infants. There was a positive association between physically demanding work and preterm births, pregnancy-induced hypertension, and delivery of small-for-gestational-age infants. Shift work alone was found to increase the incidence of preterm births. 41There is evidence that sleep restriction alters physiologic function. Significant detrimental effects on immune function can be found after a few days of total sleep deprivation or after several days of partial sleep loss. 42,43Sleep restriction of 4 h per night for six nights is associated with harmful effects on carbohydrate metabolism and endocrine function. 44This degree of sleep restriction resulted in abnormal glucose tolerance, decreased thyrotropin concentrations, increased evening cortisol concentrations, and increased sympathetic nervous system activity (as measured by heart rate variability). Sleep deprivation and circadian disruption affect cerebral metabolic and cognitive function. In a study of changes in regional cerebral glucose utilization (i.e ., positron emission tomography) during 85 h of consecutive sleep loss, decreases in cerebral metabolic rate were observed primarily in the thalamus and prefrontal and posterior parietal cortices. Alertness and cognitive performance declined in association with these brain deactivations. 45A recent study of aircrew members suggests there may be a linkage between long-term exposure to time-zone changes (i.e ., circadian disruption), temporal lobe atrophy, and deficits in learning and memory. 46Investigations using functional magnetic resonance imaging technology contradict some of the aformentioned findings and reveal compensatory changes of increased activation in the prefrontal cortex and parietal lobes during verbal learning after sleep deprivation. 47–50Studies show altered mortality with sleep loss and circadian disruption. Circadian disruption in hamsters and Drosophila reduce life span from 11 to 15%. 51,52A prospective investigation of more than one million individuals conducted by the American Cancer Society found that men who reported “usual” daily sleep times of less than 4 h were 2.8 times more likely to have died within a 6-year follow-up as men who obtained 7.0–7.9 h of sleep. 53The risk for women was increased by 48%. Conversely, men and women who reported sleeping 10 h or more per day had about 1.8 times the mortality rate of those who reported 7.0–7.9 h of sleep.The two primary determinants that underlie fatigue and interact in a dynamic manner are sleep homeostasis and circadian rhythms. 54An individual's level of alertness (e.g ., on the job) or potential for sleep (e.g ., during a rest period) will be determined by a complex interaction of these factors. Performance and alertness decrements may occur when either of these elements is disrupted. 55Factors other than fatigue, such as workload, environment, stress, boredom, motivation, and professionalism, also influence the ability to perform. 4In addition, there are large interindividual differences on the effects of fatigue. 56Sleep serves a vital physiologic need. 57Like other basic physiologic requirements such as food and water, sleep plays a fundamental role in survival. Sleep homeostasis is the balance between sleep need and quality and quantity of sleep obtained by an individual. On average, the adult human requirement for sleep appears to be greater than 8 h (8 h:14 min) per 24-h period. 58,59The range of sleep need varies from 6 to 10 h, and this requirement is probably genetically determined and cannot be “trained” to a different sleep need. 60Estimates suggest that most American adults obtain about 1–1.5 h less sleep than needed. §§This lost sleep accumulates to produce a “sleep debt.”8,58For example, an individual who obtains 1.5 h less sleep per night over a 5-day work week will begin the weekend with 7.5 h of sleep debt. This deficit is roughly equivalent to the loss of a full night of sleep and requires about two nights of at least 8 h of sleep for recovery. 20Sleep debts are not repaid hour for hour, but instead through an increase in deep sleep or nonrapid eye movement stages 3 and 4. 20A variety of factors can affect sleep quantity and quality. Perhaps some of the most dramatic changes in sleep occur as a normal function of aging. Approaching age 50 and beyond, sleep becomes more disrupted with frequent awakenings. There are reduced amounts of deep sleep, and sleep becomes less consolidated. 61Nocturia in men and menopausal symptoms in women are likely to contribute to sleep disturbances in older individuals. There are also age-related increases in complaints of insomnia and depression that negatively impact sleep. Sleep need does not necessarily decrease with age, and increased daytime sleepiness can be the consequence of reduced sleep quantity and quality. There have been no formal studies assessing whether these changes in sleep quantity and quality affect the performance of older anesthesia providers.There are approximately 90 known sleep disorders that have been described and classified in a diagnostic nosology. 62The causes for these disorders range from physiologic to psychological to environmental. Some sleep disorders are relatively prevalent in the population and have well-documented negative effects on waking alertness and performance. 63–65Often, the affected individual is unaware of their disorder, and the bed partner may be the first to identify the problem. Obstructive sleep apnea is a common example of a sleep disorder that has implications in operational settings. There are many health consequences associated with sleep apnea, but, in addition, it has been shown to be associated with a twofold to sevenfold increase in risk for automobile accidents. 66,67Consistent with this, Powell et al . demonstrated that individuals with mild to moderate sleep apnea had a decrement in performance equivalent to that of an individual with a blood alcohol concentration of 0.05–0.08 g/dl. 68Alcohol is the most widely used sleep aid, and its use is typically intended to provide relaxation or to promote sleep. 69However, alcohol is a potent suppressor of rapid-eye-movement sleep, especially in the first half of the night. 70As the blood alcohol concentration declines, there is a rapid-eye-movement rebound in the second half of the night, producing more rapid-eye-movement sleep with increased awakenings and a reduction in total sleep time. Therefore, although alcohol may be consumed as an aid to promote sleep, it actually has the potential to significantly disrupt it.Sleep can be measured both subjectively, using a variety of questionnaires, and objectively, using standardized physiologic measures. Generally, humans are inaccurate subjective reporters of alertness. 71,72Individuals can report being awake and alert, when physiologically they could be asleep in minutes. This discrepancy between self or subjective reports and physiologic levels of alertness can have significant operational implications. First, it indicates that verbal reports of subjective alertness are to an individual's for an individual with the subjective and report of being be less likely to an alertness (e.g ., or as in the on alertness that could the physiologic is important to that when an individual reports a subjective at either of the (e.g ., fatigue or it is more likely to the physiologic human circadian is in the of the and is an for 24-h rhythms. most and of the is while a of the is by the at night and is by to the direct for and exposure to affect the circadian The daily the to its 24-h The tendency of the circadian clock is to than 24-h day, is the physiologic to than work–rest In other of shift from days to to nights has a circadian physiologic but this has not been a to the of shift work. a range of and For example, it the 24-h daily and as well as alertness and performance levels. the of sleep are important and complex but are the scope of this article and are are for increased sleepiness at two times and circadian associated with the levels of and performance and vulnerability to errors, incidents, and accidents, occurs at about an example, it has been well that a in fatigue-related accidents, alcohol occurs roughly between 3 and of alertness occur at approximately and to a different work such as the night shift or time the circadian will occur for days as the to the new environmental (e.g ., the after through several time work creates a different by its disruption of the circadian individuals are working at night, circadian sleep, and when they to sleep during the day, the circadian clock is for wakefulness. Generally, studies have shown that does not occur prolonged exposure to night work. an the individual and is to daytime that maintain for a factors such as with and that can only be during daytime hours also a role in the to the rhythm to night work. study of during anesthesia has for a circadian in clinical performance among risk of was greater at night to and among this investigation is of a negative circadian effect on performance, it was by the of as well as by not including important such as patient and physician data from of anesthesiologists other that fatigue is by as a significant risk for patients. In two studies of anesthesia more than reported having an in medical that they to fatigue. et al ., using the critical of anesthetic errors, estimated that human a role in more than of anesthetic and that fatigue was an associated factor in of reported critical a of New anesthesiologists, reported that they their limit for safe continuous of and reported having a fatigue-related from reports of critical to the from to revealed that fatigue was listed as a contributing factor in reports data suggest that there is a association between fatigue and errors at circadian The from these studies are they are on but the of that quality of care is compromised and that some errors are to working while recently the effect of fatigue in the was of falling asleep while an the was that the had been by about falling asleep during was of medical and of of and The was on a as the of on the had using of accident (table the of errors and accidents that occur in the are likely to have fatigue as a contributing factor on work schedules is a well-documented association between long work hours or late work and an increased potential for from accidents. The risk of an accident increases with hour after the consecutive hour of work. effect is exaggerated when work hours occur on a late shift. injuries, among the most frequent of the injuries by anesthesia are occur during or of and are associated with from fatigue. residents and medical there is a greater risk of a exposure during night work than during have the described risks associated with drowsy driving to physicians. physicians are at risk for accident and as they after their duty In a study of an of residents h of sleep while on reported falling asleep at the compared with of These residents had as many for than the in and emergency have been reported to the of accidents, in many cases while driving after being on call. a more recent study of risk among anesthesia only accidents were which not from the this to the circadian effect during the effect of work hours on pregnancy outcomes in resident physicians has been These data reveal that there is an increased incidence of pregnancy-induced hypertension, small-for-gestational-age infants. study an association between preterm delivery and residents who worked more than 100 h per in other “24/7” health care has some where fatigue was identified as causal or contributory. most often example is the of which attention on work hours and of resident physicians. there has been much to whether was related to the providers who for a high-profile was in that recommendations to limit house work hours and to increase their These recommendations of the of the New Health (table Accreditation Council on Graduate Medical and its and program requirements for resident duty hours, and work were required to that training program formal for resident duty hours that and care of patients. The for that duty hours not be and on average, residents have least day of 7 of and be on call in the hospital no more often than every if these are residents are from anesthesia on the day after evaluation suggests that the of resident duty hours may not be the that alone patient outcome. and after implementation of the New regulations found that there were no differences in mortality rate of patient to care or of and that there were more having at least one et al . demonstrated that adverse were more common when house were for compared with times when a resident the patient was with the care. follow-up study revealed that the quality of during patient the quality of care. suggests that during some use of residents to house may the of more medical errors, but that these errors be in other is among studies on the effects of fatigue on the performance of have the in most of the studies (table is not that the of this of data are these is a studies in the used for fatigue or sleep loss. studies of partial sleep deprivation reveal that performance decrements occur if sleep is by as as h, et al . used 4 h of sleep on the night prior to performance to between and is no for the that sleep times of greater than 4 h be considered as other use study conditions. of in studies is the of a standardized to performance. A

Strive for Excellence, Not Perfection

From the American Board of Surgery, Philadelphia, Pennsylvania Correspondence: Frank R. Lewis, Jr., MD, American Board of Surgery, Suite 860, 1617 John F. Kennedy Blvd., Philadelphia PA 19103. E-mail: [email protected]

BackgroundThe impact of resident work hours on resident well-being and patient safety has long been a controversial issue.ObjectivesWhat has not been considered in resident work hour limitations is whether resident commuting time has any impact on a resident's total work hours or well-being.MethodsA self-administered electronic survey was distributed to emergency medicine residents in 2016.ResultsThe survey response was 8% (569/6828). Commuter time was 30 minutes or less in 70%. Two residents reported a commuter time of 76 to 90 minutes and one resident had a commuter time of 91 to 105 minutes. None reported commuter times greater than 105 minutes. Of most concern was that 29.3% of the residents reported falling asleep while driving their car home from work. We found 12% of respondents reporting being involved in a car collision while commuting. For residents with commute times greater than one hour, 66% reported they had fallen asleep while driving. When asked their opinion on the effect of commute time, those with commute times greater than one hour (75% of residents) responded that it was detrimental.ConclusionsWhile the majority of emergency medicine residents in this survey have commuter times of 30 minutes or less, there is a small population of residents with commuter times of 76 to 105 minutes. At times, residents whose commute is up to 105 minutes each way could be traveling a total of more than 3.5 hours for each round trip. Given that these residents often work 12-hour shifts, these extended commuter times may be having detrimental effects on their health and well-being.

Physicians work hours: desperately seeking evidence

To assess the educational impact of Accreditation Council for Graduate Medical Education resident work-hour limits implemented in July 2003. All trainees in all 76 accredited programs at two large teaching hospitals were surveyed between May and June 2003 (before work-hour reductions) and then between May and June 2004 (after work-hour reductions) about hours, education, and fatigue. Based on changes in weekly duty hours, 13 programs experiencing substantial reduction in hours were classified into a reduced-hours group. Differences in assessments of educational endpoints before and after policy implementation by trainees in the reduced-hours group were compared with those in other programs to control for potential temporal trends, using two-way ANOVA with interaction. The number of respondents was 1,770 (60% response rate). The reduced-hours group reported a significant decrease in time spent directly caring for patients (from 48.5 to 42.3 mean h/wk, P = 0.03), but the volume of important clinical experiences, including procedures, was preserved, as was the sense of clinical preparedness. On 22 questions related to educational quality and adequacy, only three differences in differences were significant, with the reduced-hours group reporting a relative increase in opportunities for research, decrease in quality of faculty teaching, and decrease in educational satisfaction. The percentage of trainees reporting frequent negative effects of fatigue dropped more in the reduced-hours programs than in the other programs (P < 0.05). This study shows that it may be possible to reduce residents' hours--and the perceived adverse impact of fatigue--while generally preserving the self-assessed quality, quantity, and outcomes of graduate medical education.

The Emergency Nurses Association (ENA) “Weighs in” on Pediatric Medication Safety: “Weigh Children in Kilograms Only!”

Intern Workload and Discontinuity of Care on 30-Day Readmission

Examining influential, highly cited articles can show the advancement of knowledge about the effect of resident physicians' long work hours, as well as the benefits and drawbacks of work hour limits. A narrative review of 30 articles, selected for their contribution to the literature, explored outcomes of interest in the research on work hours-including patient safety, learning, and resident well-being. Articles were selected from a comprehensive review. Citation volume, quality, and contribution to the evolving thinking on work hours and to the Accreditation Council for Graduate Medical Education standards were assessed. Duty hour limits are supported by the scientific literature, particularly limits on weekly hours and reducing the frequency of overnight call. The literature shows declining hours and call frequency over 4 decades of study, although the impact on patient safety, learning, and resident well-being is not clear. The review highlighted limitations of the scientific literature on resident hours, including small samples and reduced generalizability for intervention studies, and the inability to rule out confounders in large studies using administrative data. Key areas remain underinvestigated, and accepted methodology is challenged when assessing the impact of interventions on the multiple outcomes of interest. The influential literature, while showing the beneficial effect of work hour limits, does not answer all questions of interest in determining optimal limits on resident hours. Future research should use methods that permit a broader, collective examination of the multiple, often competing attributes of the learning environment that collectively promote patient safety and resident learning and well-being.

Impact of extended duty hours on medical trainees

Limiting resident work hours may improve patient safety, but unintended adverse effects are also possible. We sought to assess the impact of Accreditation Council for Graduate Medical Education resident work hour limits implemented on July 1, 2003, on resident experiences and perceptions regarding patient safety. All trainees in 76 accredited programs at 2 teaching hospitals were surveyed in 2003 (preimplementation) and 2004 (postimplementation) regarding their work hours and patient load; perceived relation of work hours, patient load, and fatigue to patient safety; and experiences with adverse events and medical errors. Based on reported weekly duty hours, 13 programs experiencing substantial hours reductions were classified into a "reduced-hours" group. Change scores in outcome measures before and after policy implementation in the reduced-hours programs were compared with those in "other programs" to control for temporal trends, using 2-way analysis of variance with interaction. A total of 1770 responses were obtained (response rate, 60.0%). Analysis was restricted to 1498 responses from respondents in clinical years of training. Residents in the reduced-hours group reported significant reductions in mean weekly duty hours (from 76.6 to 68.0 hours, P < .001), and the percentage working more than 80 hours per week decreased from 44.0% to 16.6% (P < .001). No significant increases in patient load while on call (patients admitted, covered, or cross covered) were observed. Between 2003 and 2004, there was a decrease in the proportion of residents in the reduced-hours programs indicating that working too many hours (63.2% vs 44.0%; P < .001) or cross covering too many patients (65.9% vs 46.9%; P = .001) contributed to mistakes in patient care. There were no significant reductions in these 2 measures in the other group, and the differences in differences were significant (P = .03 and P = .02, respectively). The number of residents in reduced-hours programs who reported committing at least 1 medical error within the past week remained high in both study years (32.9% in 2003 and 26.3% in 2004, P = .27). It is possible to reduce residents' hours without increasing patient load. Doing so may reduce the extent to which fatigue affects patient safety as perceived by these frontline providers.

Purpose: Flexible working hours can impact employee productivity. Therefore, the current research aimed to present a model for flexible working hours in public organizations, emphasizing increasing the productivity level of knowledge workers. Methodology: The present study was applied in objective and mixed-method (qualitative and quantitative) in execution. The qualitative study population included all academic and organizational experts familiar with the research domain, with a sample size of 25 determined based on theoretical saturation principle and selected through purposive sampling. The quantitative study population comprised all staff members of the Ministry of Cooperatives, Labor, and Social Welfare, with a sample size of 205 determined by Cochran's formula and selected through simple random sampling. Data for qualitative and quantitative sections were collected respectively using interviews and researcher-made questionnaires and analyzed with thematic analysis and exploratory factor analysis methods in Maxqda and Smart-PLS software, respectively. Findings: Qualitative findings revealed that flexible working hours encompassed 15 sub-themes in 3 main themes: floating work hours, floating work location, and collaborative work; and employee productivity comprised 20 sub-themes in 3 main themes: self-management, self-control, and self-organization. Quantitative findings indicated that all themes of flexible working hours and employee productivity had a factor loading and extracted variance mean higher than 0.50 and Cronbach's alpha and composite reliability higher than 0.80. Other findings showed that the themes of floating work hours, floating work location, and collaborative work had a direct and significant effect on flexible working hours, and the themes of self-management, self-control, and self-organization had a direct and significant effect on employee productivity, and flexible working hours had a direct and significant effect on employee productivity (P&lt;0.05). Conclusion: The results of this study indicate that flexible working hours play an effective role in enhancing the level of employee productivity. Therefore, to improve employee productivity, the themes of floating work hours, floating work location, and collaborative work can be utilized.

The article examines transformation of the legal regulation of flexible working hours, home-based work and teleworking in Ukraine in the context of the experience of foreign countries during the COVID-19 pandemic. It is investigated that under quarantine conditions the application of these forms of labour organization has increased and their legislative regulation in Ukraine and foreign countries has improved. Currently, in Ukraine flexible working hours are applied not only to employees who work under an employment contract, but also to government employees. The legal regulation of home-based work and teleworking has undergone some transformations from their initial identification to the subsequent differentiation. Legislative consolidation of teleworking has led to the establishment of a new institution, namely the right to disconnect (the period of free time of the employee who works remotely). Comparative characteristics of flexible working hours, home-based work and teleworking according to the laws of Ukraine are identified. It has been found that the legalization of non-traditional forms of labour organization including flexible working hours, home-based work and teleworking under quarantine conditions has allowed maintaining the stability of labour relations, ensuring social distance of workers and reducing the morbidity level during the COVID-19 pandemic.