Clinical and educational work hours

  1. Definition
    Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care responsibility, time spent in- house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.
  2. Requirements
    1. All Programs, regardless of their accrediting body, are required to meet the ACGME Institutional Requirements related to duty hours as well as all Residency Review Committee requirements as described in the Program Requirements for each specialty.
    2. Each Residency Training and Fellowship Program will establish a formal policy governing resident duty hours and working environment. This policy must comply with the ACGME Common Program Requirements as well as that specialty's Residency Review Committee Program Requirements. Such policies are designed to optimize both resident education and the care of patients.
  3. Policy
    1. Work Hours:
      1. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. The four week period must be within the same rotation, i.e. a two week research rotation cannot be averaged with a clinical rotation. Exceptions (for up to an additional 10%) will require UNR Med GMEC and RRC approval.
      2. Duty periods for PGY1 residents must not exceed 16 hours in duration.
      3. Duty periods for PGY2 residents and above may be scheduled up to a maximum of 24 hours and must not be assigned additional clinical responsibilities after 24 hours of continuous duty. These residents may be allowed to remain on-site for a maximum of four additional hours in order to accomplish effective transitions of care (28 hours total in house).
      4. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
      5. PGY1 residents should have 10 hours and must have eight hours free of duty between scheduled duty periods. Intermediate level residents (as defined by the program specific review committees) should have 10 hours free of duty and must have eight hours between scheduled duty periods. Intermediate residents must have at least 14 hours free of duty after 24 (plus 4 hours) of in house duty.
      6. Residents must not be scheduled for more than six consecutive nights of night float.
      7. Programs must have a system for tracking resident work hours and must be able to document the number of hours each resident works each week.
      8. Each program must have a written policy and procedure regarding work hours that is consistent with this institutional policy and must submit that departmental policy and annual updates of that policy to the Office of Graduate Medical Education each July.
    2. On Call Activities:
      1. In-house call is defined as work hours beyond the normal work day when residents are required to be immediately available in the assigned institution.
        1. PGY2 residents and above must not be scheduled in-house call more frequently than every third night, averaged over a four week period.
        2. Duty periods of PGY2 residents and above may be scheduled up to a maximum of 24 hours and must not be assigned additional clinical responsibilities after 24 hours of continuous duty. Residents may be allowed to remain on-site for a maximum of four additional hours in order to accomplish effective transitions of care.
        3. No new patients may be accepted after 24 hours of continuous duty. A new patient is defined as any patient for whom the resident has not previously provided care.
      2. At-home call (pager call) is defined as call taken from outside the assigned institution.
        1. Residents/fellows are permitted to return to the hospital while on at- home call to care for new or established patients. Each episode of this type of care must be included in the 80 hour weekly maximum but will not initiate a new "off duty" period.
        2. At home call must not be so frequent as to preclude rest and reasonable personal time for each resident/fellow. Residents/fellows taking at home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a four week period.
        3. The program must develop a procedure for monitoring the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. The program must develop a procedure for tracking the number of hours spent in the hospital from at-home call.
      3. Each program must have a written policy and procedure regarding on-call activities (may be incorporated into the work hours policy) that is consistent with this institutional policy and must submit that policy and annual updates of that policy to the Office of Graduate Medical Education each July.
    3. Moonlighting
      1. Professional and patient care activities that are external to the educational program are called "moonlighting". Programs must ensure that moonlighting activities do not interfere with the ability of residents/fellows to achieve the goals and objectives of the educational program
      2. Each program must have a written policy and procedure regarding moonlighting that is consistent with the institutional policy for moonlighting (moonlighting policy). That department policy and annual updates of that policy must be submitted to the Office of Graduate Medical Education each July.
      3. All moonlighting - both internal and external - must be included in the 80 hour weekly work hour maximum
      4. PGY1 residents are not permitted to moonlight.
    4. Back up System
      1. Each program must develop a back-up system to cover patient care responsibilities when those responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident/fellow fatigue sufficient to jeopardize patient care.
      2. Each program must have a written policy and procedure consistent with the institutional GME policy regarding back-up systems and that department policy and annual updates must be submitted to the Office of Graduate Medical Education every July.
    5. The following principles underlie all program-specific duty hours policies:
      1. The educational goals of the program and learning objectives of residents must not be compromised by excessive reliance on residents to fulfill institutional service obligations. Duty hours, however, must reflect the fact that responsibilities for continuing patient care are not automatically discharged at specific times. Programs must ensure that residents are provided backup support when patient care responsibilities are especially difficult or prolonged.
      2. Resident duty hours and on-call schedules must not be excessive. The structuring of duty hours and on-call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident. Duty hours must be consistent with the institutional and program requirements that apply to each program.
      3. The institution must provide services and develop systems to minimize the work of residents that is extraneous to their educational program.
  4. Graduate Medical Education Requirements
    1. Program Directors will provide a written copy of their duty hours policy to the Office of Graduate Medical Education at the beginning of each academic year.
    2. Program directors MUST provide a written copy of their duty hours policy to their faculty and house staff at the beginning of each academic year.
    3. Program Directors are responsible for monitoring the effects of duty hours responsibilities and making necessary modifications to scheduling in order to mitigate excessive service demands or fatigue.
      1. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service. Quarterly reports should be provided to the Office of Graduate Medical Education for review and potential discussion at GMEC meetings.
      2. Duty hours policies will be evaluated at the time of internal review of the training program.
      3. Compliance with duty hours regulations will be evaluated quarterly. Non- adherence will be reported to the GMEC for further action.
  5. Institutional Support
    UNR Med provides institutional support for both residents and fellows through institutional compliance monitoring.
    • The Office of Graduate Medical Education reviews ACGME duty hours for each program. Any reports of non-adherence of duty hours policies will be investigated and reported to the GMEC for discussion and action.
    • The GME website provides for a confidential reporting mechanism where violations of duty hours may be reported anonymously and untraceably. Reporting a violation triggers an email to the Office of Graduate Medical Education for an independent investigation while protecting the anonymity of any individual reporting a potential violation.