Policy on Monitoring and Reporting Duty Hours Compliance
EFFECTIVE JULY 1, 2003
Monitoring and Reporting Duty Hours to Assure Program Compliance
I. Purpose and Objectives:
On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated that sponsoring institutions and all of their accredited training programs, must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. It is further expected that the mission to educate house staff should reflect our responsibility to our patients, fellow physicians and the community that the physicians training in our Graduate Medical Education programs are physically and mentally prepared to meet their designated responsibilities. Each training program will outline a system that provides fluid communication between faculty, house staff and other patient care representatives that ensures continued patient care at all times.
The purpose of this policy is to outline the method that will be used by the Office for the Associate Dean for Graduate Medical Education, and the Graduate Medical Education Committee (GMEC) to monitor and confirm a sponsored programs’ compliance with the ACGME duty hour limitations. It is also the intent of this policy to identify the process that will be used for programs that remain out of compliance with the stated requirements.
II. Definitions:
Duty Hours: “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, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading time and preparation time spent away from the duty site”.
(ACGME Common Program Requirements, effective 7/1/03)
In-house Call: In-house call includes all patient care activities required of house staff that must take place within the duty site. In-house moonlighting includes all patient care outside of the training program curriculum but performed within the sponsoring hospital. This time must be included in the 80-hour limit and be closely monitored by the program director. All other policies on moonlighting still apply. When it is required for house staff to come in-house to render patient care, the time in-house will count toward the duty hour limit.
Home/Pager Call: Home/Pager call is defined as call taken outside the duty site, which does not necessitate coming into the duty site to administer care for patients. Programs must monitor the frequency of phone calls during home call to ensure the opportunity for adequate rest. This time should not be counted toward the 80-hour limit.
Moonlighting/Outside Employment: Moonlighting/Outside Employment is defined as the assumption of any medical care responsibilites outside the Training Programs of the GME Consortium and affiliated hospitals. Training Programs may offer moonlighting options. However, Residents and Clinical Fellows are not required to participate. If the Program Director grants such authorization, the Resident/Clinical Fellow must obtain written authorization from the Program Director or his designee. This authorization must be retained in the Resident/Clinical Fellows file for future reference. The authorization must include at a minimum, the location where moonlighting will occur, the privileges granted and circumstances under which moonlighting options will be withdrawn. Training programs are encouraged to utilize the "Request for Moonlighting Privileges" form developed by the Graduate Medical Education Committee (GMEC), which can be found on the GME website at http://medicine.wustl.edu/gme under the link for Educational Coordinators.
III. Common Program Requirement Provisions:
· Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
· One 24-hour span of time in seven days (averaged over four weeks) free from all educational and clinical responsibilities must be provided to all house staff.
· In house call must be no more frequently that every third night, averaged over a four-week period.
· 6-hours post call can be used for transfer of patient care, maintenance of medical and surgical care, outpatient continuity clinics and didactic activities. Program directors are encouraged to review the most recent version of the relevant RRC Program Requirements to identify specialty specific interpretation of acceptable patient care activity during this time. A 10 hours period for rest and personal time should be provided between all daily duty periods, and after in-house call.
· Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 as outlined above.
· No new patients may be accepted after 24 hours of continuous duty, except in outpatient continuity clinics. A new patient is defined as any patient for whom the resident has not previously provided care. Program directors are encouraged to review the most recent version of the relevant RRC Program Requirements to identify specialty specific interpretations of acceptable patient care activity during this time.
IV. Process:
All sponsored programs are expected to:
A. Develop Program Policies: Sponsored programs will develop and/or enhance program specific policies on Duty Hours. Programs are to include in the policy on duty hours scheduled duty hours for each rotation, template or sample call schedule to document the program’s plan for compliance and the method the program will use to survey the house staff to confirm compliance. These policies will be made available to the internal review team at the time of the next internal review of the program. Programs are to survey house staff on a quarterly basis and adjust schedules as needed to meet the requirements.
B. Back-Support: Programs must provide back up support to relieve house staff from patient care responsibilities to ensure house staff remain in compliance with duty hour limitations, and/or when issues of fatigue due to prolonged or difficult duty is identified.
C.Collect Data: Each program will identify a reliable survey method for the collection of raw data that will be used to verify the program’s compliance with the requirements. The data collected must be made available to the internal review team, and external site visitors (upon their request) during future internal and external reviews. Faculty and house staff must be educated on the correct use of the method chosen to assure consistent, reliable data collection.
D. Attest to Compliance: The Office for the Associate Dean for GME will require each program director to attest to his/her program’s compliance annually when the program submits their annual update to the ACGME WebAccreditation Data System. A copy of the WebADS submission must be reviewed and signed by the program director attesting to its accuracy. The duty hour information reported in WebADS must be based on the raw data collected by the training program. All questions in the report must be answered before submitting a copy to the Office of the Associate Dean for GME and the ACGME. Programs found out of compliance may undergo an immediate internal review and/or follow up action by the Internal Review Subcommittee.
E. Surveys: The Office for the Associate Dean for GME will twice yearly conduct an anonymous survey of house staff in each accredited program to confirm the house staff’s perception of the program’s compliance. Portions of the ACGME Resident Survey on Work Hours will be used in this process. Programs reported out of compliance may undergo an immediate internal review and/or follow up action by the Internal Review Subcommittee.
F. GMEC Requests for Increases Beyond the 80-Hour Limit: Programs may request approval from the full GMEC for a 10% increase in the 80-hour limit if they believe this increase is necessary to fulfill their educational requirements. This would be on a rotation by rotation basis rather than a general increase in duty hours. Program directors with rotations needing a 10% increase will present the educational rationale to the full GMEC for institutional approval. Requests must be in writing and available for distribution to the GMEC voting members at least two weeks (14 days) prior to the next regularly scheduled GMEC meeting. All requests must include the educational rationale, most recent RRC Letter of Report, the most recent internal review report, a current schedule of house staff work hours for that rotation, and the results of the anonymous survey of house staff utilizing the ACGME survey format to be administered by the Office of the Associate Dean for GME and the results shared with the program director prior to the GMEC meeting. Directors requesting the increase will be provided time during the next GMEC meeting to present their information to the members present.
During that GMEC meeting, the director of the program under review, will excuse him/herself and their designee from the voting process. The members present will have an opportunity to discuss the information and vote to approve or disapprove the request based on the educational needs of the program. Service requirements will not be sufficient to justify the increase. All other duty hour limitations will still apply and are not subject to requests for modifications.
If the GMEC approves the request, the outline reviewed by the GMEC members, and a letter of support from the Chair of the GMEC will be submitted for review to the respective RRC for final approval. The full GMEC will be advised of all final decisions by the RRC once a decision is known.
If the GMEC disapproves the request, the members present must outline the reason(s) for rejecting the request. If the program is currently out of compliance with the duty hour requirements, suggestions from the members to assist the director in bringing the rotation into compliance with the standards are highly encouraged. The director will be required to return to the GMEC in 90 days to update the GMEC members of its progress in meeting the standards. If the program remains out of compliance, the GMEC members may request follow up action at this time.
GMEC Approval March 24, 2003
GME Board Approval May 12, 2003
Effective Date July 1, 2003
Editorial Revisions 1/24/2005