Job performance, fatigue, sleep, healthcare


Fatigue in healthcare providers has been linked to dangerous outcomes for patients, including medical errors, surgical complications, and accidents. Resident physicians, who traditionally work long hours on minimal sleep, are among the most fatigued. In attempt to mitigate the impact of fatigue on resident physician performance and improve patient safety, the Accreditation Council for Graduate Medical Education (ACGME) implemented a fatigue intervention program in 2011 for medical residency programs in the United States. This caused a significant decrease in the number of hours that first-year residents were permitted to work, compared with hours worked by first-year residents in prior years. While studies investigating the impact of the 2011 ACGME fatigue intervention on outcomes are limited thus far, some initial evidence seems to be promising. For instance, Pepper, Schweinfurth, and Herrin (2014) found that the rate of transfers to the intensive care unit after a code blue significantly decreased from pre- to post-intervention. However, it is not currently understood what variables may drive positive changes in patient outcomes, nor how long it may take for these changes to occur. Thus, the purpose of this study was to examine the effect that the 2011 ACGME fatigue intervention has had on job performance in healthcare providers in U.S. hospitals. The current study attempted to address this question by taking both a micro perspective, by drawing upon cognitive theories (Kahneman, 1973, 2011) and skill acquisition theory (Fitts, 1964; Fitts & Posner, 1967), as well as a macro perspective, by drawing upon organizational change theories (DiMaggio & Powell, 1983). This study combined public-use databases provided by the Center for Medicare and Medicaid Services (CMS). Specifically, 1,277 hospitals in the United States were examined over a five year period on job performance behaviors to determine if there was significant change from pre-intervention to post-intervention. Hospitals were categorized as control hospitals (n = 594) and intervention hospitals (n = 683). More specifically, intervention hospitals were analyzed according to their resident-to-patient bed ratio, using guidelines provided by Patel et al. (2014), including very low resident-to-bed ratio hospitals (n = 174), low resident-to-bed ratio hospitals (n = 287), high resident-to-bed ratio hospitals (n = 143), and very high resident-to-bed ratio hospitals (n = 79). Further, organizational size was examined as a moderator. The current study used discontinuous growth modeling (Bliese, 2008; Ployhart, 2014; J. D. Singer & Willett, 2003) to analyze the data, which allowed for investigation into the magnitude and rate of change from pre- to post-intervention. Results show that there was a significant improvement in employee job performance over time across both intervention and control hospitals. In particular, job performance significantly improved abruptly at the transition period (i.e., when the intervention was introduced) and continued to improve gradually throughout the post-intervention period; yet, these results held for both intervention and control hospitals. However, exploratory analyses comparing control hospitals to very high resident-to-bed ratio hospitals found that the latter group improved significantly more at the transition period in comparison to control hospitals. I therefore conclude that there may be some effect of the fatigue intervention on job performance, but this effect may be visible only in very high resident-to-bed ratio hospitals. Further, organizational size was not a significant moderator of the relationship. Future research is needed to confirm these findings.


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Graduation Date





Salas, Eduardo


Doctor of Philosophy (Ph.D.)


College of Sciences



Degree Program

Psychology; Industrial & Organizational Track








Release Date


Length of Campus-only Access

1 year

Access Status

Doctoral Dissertation (Open Access)


Dissertations, Academic -- Sciences; Sciences -- Dissertations, Academic