GME Policy and Procedure
XIV.  Working/Duty Hours
ACGME Requirements
Resident Duty Hours and the Working Environment
1. Supervision of Residents
2. Duty Hours
3. Moonlighting
4. Oversight
College of Medicine Requirements
  
14.1 ACGME Requirements
A. The following is a summary of the ACGME General Requirements regarding resident working  hours.  Programs will be expected to meet the General Requirements as well as any additional requirements described in the Special Requirements for each specialty.  The ACGME approved these requirements as of September 26, 2010, for insertion into the common program requirements for all core and subspecialty programs by July 1, 2011.
  
B. Resident Duty Hours and the Working Environment
Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents' time and energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.
  
1. Supervision of Residents
a. In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as approved by each RRC) who is ultimately responsible for that patient's care
1) This information should be available to residents, faculty members, and patients.
2) Residents and faculty members should inform patients of their respective roles in each patient's care.
b. The program must demonstrate that the appropriate level of supervision is in place for all residents who care for patients.  Some activities require the physical presence of the supervising faculty member.  For many aspects of patient care, the supervising physician may be a more advanced resident or fellow.  Other portions of care provided by the resident can be adequately supervised by the immediate availability of the supervising faculty member or resident physician, either in the institution, or by means of telephonic and/or electronic modalities.  In some circumstances, supervision may include post-hoc review of resident-delivered care with feedback as to the appropriateness of that care.
c. To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision, and implement the supervision as described in the ACGME Common Program Requirements:
1) Direct Supervision – the supervising physician is physically present with the resident and patient.
2) Indirect Supervision – with direct supervision immediately available to provide Direct Supervision, or with the supervising physician immediately available by telephonic or electronic means.
3) Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
  
2. Duty Hours
  
a. 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 relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.
  
b. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities and all moonlighting.  An RRC may grant exceptions for up to 10% or a maximum of 88 hours to individual programs, based on a sound educational rationale.  The 88-hour exception is not allowed for PGY1 residents.   
  
c. Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks).  At-home call cannot be assigned on those free days. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
d. Duty periods of PGY1 residents must not exceed 16 hours in duration.
e. Duty periods of PGY2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.  Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities.  Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 pm and 8:00 am, is strongly suggested.
1) Residents may be allowed to remain on-site for no longer than an additional four hours for patient transitions.  Residents may not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
2) In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient.  Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.  Under those circumstances, the resident must:
a) Appropriately hand over the care of all other patients to the team responsible for their continuing care.
b) Document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director.
The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.
f. PGY1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods.
g. Intermediate-level residents (as defined by each RRC) should have 10 hours free of duty, and must have eight hours between scheduled duty periods.  They must have at least 14 hours free of duty after 24 hours of in-house duty.
h. Residents in the final years of education (as defined by each RRC) must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.  This preparation must occur within the context of the 80-hour, maximum duty period length, and one-day-off-in-seven standards.  There may be circumstances (defined by the RRC) when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty.  Circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by residents in their final years of education must be monitored by the program director.
i. Night Float is defined as rotation or educational experience designed to either eliminate in-house call or to assist other residents during the night.  Residents assigned to night float are assigned on-site duty during evening/night shifts and are responsible for admitting or cross-covering patients until morning and do not have daytime assignments.  Rotation must have an educational focus.
1) Residents must not be scheduled for more than six consecutive nights of night float.
2) The maximum number of consecutive weeks of night float, and maximum number of months of night float per year, may be further specified by each RRC.
j. In-House Call is defined as duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution.  PGY2 residents and above must be scheduled for in-house call no mare frequently than every-third-night (when averaged over a four-week period).
k. At-Home Call (also known as Pager Call) is defined as a call taken from outside the assigned site. Time in the hospital, exclusive of travel time, counts against the 80 hour per week limit but does not restart the clock for time off between scheduled in-house duty periods.  At-Home Call may not be scheduled on the resident's one free day per week (averaged over four weeks).  The frequency of at-home call is not subject to the every-third-night limitation.
1) At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.
2) Residents 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, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period.”
  
3. Moonlighting
a. Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program.
b. The program director must comply with the sponsoring institution's written policies and procedures regarding moonlighting, in compliance with the ACGME Institutional Requirements and Common Program Requirements.
c. Time spent by resident in internal and external moonlighting (as defined in the ACGME Glossary of Terms) must be counted toward the 80-hour weekly hour limit.
  
4. Oversight
a. The program director must administer and maintain an educational environment conducive to educating the residents in each of the ACGME competency areas.  Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment, including moonlighting, and to that end, must:
1) Distribute these policies and procedures to the residents and faculty.
2) Monitor resident duty hours, according to UIC institutional policies, with a frequency sufficient to ensure compliance with ACGME requirements.
3) Adjust schedules as necessary to mitigate excessive service demands and/or fatigue.
4) If applicable, monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue.
5) Monitor the need for and ensure the provision of back up support systems when patient care responsibilities are unusually difficult or prolonged.
  
14.2 College of Medicine Requirements
A. Program Directors will provide a written copy of their resident working hour policy to the GME Office upon request by the Office.  The Director of the Office of GME will provide a summary of individual program policies to the GMEC on a periodic basis.
B. Program Internal Reviews will include a survey of actual resident assignments to determine compliance with programmatic as well as ACGME requirements on working hours.  Discrepancies will be reported to the GMEC for further action.
C. Residents will be required to complete an anonymous rotation evaluation form for each rotation.  That evaluation will include a section regarding duty hours.  The Program Director and the Office of GME will monitor the summary information and will take necessary corrective action when compliance issues are reported.
D. The Office of GME will develop additional compliance measures as needed, including but not limited to auditing of call schedules and periodic surveys of residents.  Discrepancies will be reported to the GMEC for further action.
E. All recommendations by programs for an increase in duty hours must receive approval of the GMEC prior to being submitted to the ACGME, and must include the following documentation:
1. Educational rationale for the request, stated in terms of the program's goals and objectives for the particular assignments, rotations, and levels of training for which the increase is requested.
2. Information on how the program will monitor, evaluate, and ensure patient safety with the extended work hours.
3. Specific information regarding the program's moonlighting policies.
4. Specific information regarding resident call schedules during the times specified for the exception.
5. Evidence of faculty development activities regarding the effects of resident fatigue and sleep deprivation.


Policy and Procedure     XIV. Working/Duty Hours
Approved: December 20, 1993
Joint Committee on Graduate Medical Education
Reviewed: February 28, 1997 GMEC
July 9, 1999 GMEC
August 1, 2003 GMEC
February 3, 2006 GMEC
October 7, 2011