Policy of the Graduate Medical Education Committee

Section: Resident Supervision/ Work Environment 

Subject: Duty Hours and Learning/Work Environment

Number: 3.200

Date Developed: 7/98
Last Review/Revision: 10/04, 1/08, 1/11
Replaces:  Previous policy of same name, dated 1/08

ACGME Requirements: Institutional II.D.i, II.F: Common VI; RRC Procedures for Granting Duty Hours Exceptions

Purpose

To establish University of Arkansas for Medical Sciences College of Medicine standards for duty hours in the learning and working environment for residents (includes fellows).

Definitions

Duty hours:  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, didactic sessions or assigned research duties. Duty hours do not include reading and preparation time spent away from the duty site.

In-house call: those duty hours beyond the normal workday when residents are required to be immediately available in the assigned institution.

At-home call (pager call): call taken from outside the assigned institution.

Ancillary support: defined as, but not limited to, the following:  Drawing blood, obtaining EKGs, transporting patients, securing medical records, securing tests results, completing forms to order tests and studies, monitoring patients after procedures.  Except in unusual circumstances, providing ancillary support should not be the resident’s responsibility except for specific educational objectives or as necessary for patient care.

Policy

Background: Each Program Director must establish and implement formal written policies and procedures governing duty hours and work environment for residents, which comply with this institutional GMEC policy and the Common and Specialty-specific Program Requirements.  Programs must be committed to and responsible for promoting patient safety and resident well-being in a supportive educational environment. The learning objectives of the program must be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events; and must not be compromised by excessive reliance on residents to fulfill non-physician service obligations.  The ACGME has delineated the concept of duty hours into multiple overarching categories, with corresponding specifications, listed below.

Professionalism, Personal Responsibility, and Patient Safety

The program director and institution must ensure a culture of professionalism that supports patient safety and personal responsibility.  All residents and faculty members must demonstrate responsiveness to patient needs that supersedes self-interest.  Physicians must recognize that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider.  Residents and faculty members must demonstrate an understanding and acceptance of their personal role in the following:

1.      Assurance of the safety and welfare of patients

2.      Provision of patient- and family-centered care

3.      Assurance of their fitness for duty

4.      Management of their time before, during, and after clinical assignments

5.      Recognition of impairment, including illness and fatigue, in themselves and their peers

6.      Attention to lifelong learning

7.      The monitoring of their patient care performance improvement indicators

8.      Honest and accurate reporting of duty hours, patient outcomes, and clinical experience data

Transitions of Care

1.      Programs must design clinical assignments to minimize the number of transitions in patient care

2.      Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety

3.      Programs must ensure that residents are competent in communicating with team members in the hand-over process.

Clinical Responsibilities

The clinical responsibilities for each resident must be based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services. (further specified by RRCs)

Teamwork

Residents must care for patients in an environment that maximizes effective communication. 

This must include the opportunity to work as a member of effective inter-professional teams that are appropriate to the delivery of care in the specialty.  (further specified by RRCs).

Duty Hours

Programs will comply with resident duty hours and definitions as set forth in the applicable Program Requirements.

Work Environment

Food Services:  Residents on duty must have access to adequate and appropriate food services. Food is provided to residents who take in-house call.

Call Rooms: Call rooms are provided for residents who take in-house call.

Support Services: Adequate ancillary support for patient care shall be provided for residents at all times. Laboratory/pathology/radiology services: these services and the associated information systems must be available and adequate to support timely and quality patient care.

Medical Records:  Medical records system that document the course of each patient’s illness and care must be available at all time and must be adequate to support quality patient care, the education of residents, quality assurance and provide a resource for scholarly activity.

Security/safety: Appropriate security and personal safety measures must be provided to residents at all locations.

Oversight

1. Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment. These policies and procedures must be distributed to the residents and the faculty.
2. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.
3. Each Program Director should review each resident’s rotational schedule to assure compliance with this institutional policy and the Common Program Requirements, and should document and monitor unusual patient care circumstances that require an extension of a duty period as specified above and in the Common Program Requirements.
4. Each Program Director should regularly monitor resident duty hours for compliance with this institutional policy and the Common Program Requirements. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service.
5. The GMEC shall monitor compliance with this policy through the:

a.       Internal review of each program

b.      Annual GME Survey of  residents

c.       Periodic monitoring of individual programs

Falsification of duty hour’s data or pressure to cause the falsification of such data is considered egregious behavior for residents and can result in disciplinary action to include dismissal.  Faculty members are governed by the Faculty Group Practice and University policies and procedures and terms of the Faculty Group Practice agreement.  Residents must notify the Program Director of requests or pressure to work in excess of duty hours authorized by this policy.   

Duty Hours Exceptions
An RRC may grant exceptions for up to 10 % of the 80-hour limit, to individual programs based on a sound educational rationale. The GMEC must review and formally endorse the exemption prior to submission to the RRC according to the following procedures:

1.   The Program Director must submit a written request for an exemption to the GMEC Chair. The request must clearly document the following:

a.   Patient Safety: Information must be submitted that describes how the program and institution will monitor, evaluate, and ensure patient safety with extended resident work hours.

b.   Educational Rationale: The request must be based on a sound educational rationale which should be described in relation to the program's stated goals and objectives for the particular assignments, rotations, and level(s) of training for which the increase is requested. Blanket exceptions for the entire educational program should be considered the exception, not the rule.

c.   Moonlighting Policy: Specific information regarding the program's moonlighting policies for the periods in question must be included.

d.   Call Schedules: Specific information regarding the resident call schedules during the times specified for the exception must be provided.

e.   Faculty Monitoring: Evidence of faculty development activities regarding the effects of resident fatigue and sleep deprivation must be appended.

2.   The Program Director will present the request in person to the GMEC for discussion.. 

3.   If approved by the GMEC, the Designated Institutional Official (DIO) or the GMEC Chair will provide a documented written statement of institutional endorsement of the proposal.

4.   The Program Director must submit the request to the RRC according to the ACGME’s RRC Procedures for Granting Duty Hours Exceptions. The proposal to the RRC must include a copy of this policy (which contains the institution's written procedures and criteria for endorsing requests for an exception to the duty hours limits) and the current accreditation status of the program and of the sponsoring institution.