Work Hour Compliance Monitoring

Clinical and Educational Work Hours are defined as all clinical and academic activities related to the training program.

This includes: inpatient and outpatient clinical care, in house call, short call, night float and day float, transfer of patient care, and administrative  activities related to patient care such as completing medical records, ordering and  reviewing lab tests, and signing orders. This also includes time spent doing clinical work while on home call, moonlighting activities, and other scheduled activities, such as  conferences. Clinical and Educational Work hours do not include reading done in  preparation for cases, studying, and research done away from the duty site. Clinical and  Educational Work Hours will hereafter be referred to as “Work Hours”.  

Continuous time on duty: The period that a resident or fellow (hereafter referred to as  “resident” or “trainee”) is in the hospital (or other clinical care setting) continuously,  counting the resident’s regular scheduled day, time on call, and the hours a resident  remains on duty after the end of the on-call period to transfer the care of patients and for  didactic activities.   

In-house call: Work hours beyond the normal work day when residents are required to be  immediately available in the assigned institution.  

Scheduled work periods: Assigned work within the institution encompassing hours which  may be within the normal work day, beyond the normal work day, or a combination of  both.  

The system is designed to be proactive in identifying potential work hour violations rather then being reactive and identifying actual violations. There are times when a violation will be displayed for an individual resident timesheet that is technically not a violation when averaged over the full four week period.

A Four-week calculation will determine whether the individual timesheet violation was actually an ACGME duty hour violation. Programs can click “Resident Work Hours”, and trainees can click “This week’s work hours” from the MedHub homepage and then “Work Hour History”. The system indicates true violations with a red X and false violations with a green checkmark.

Residents are able to document duty hours on a two week rolling basis. At any given time, residents have access to the current week and previous week’s duty hours. Each Sunday Residents lose access to one week and gain access to the next week. Program Administrators have access to modify resident duty hours until the 15th of the current month for the previous month before lockout occurs.

Program Administrators have access to the previous month’s work hours until the 15th of the current month. For example, Program Administrators can edit and submit (on a trainee’s behalf) work hours from March 1st-31st until the 15th of April.

No, GME will not unlock work hours.

See MedHub Work Hour Violation Calculations for a breakdown of each work hour violation.

The Primary Administrator for the program may access Residents > Work Hours > Work Hour Reviews. They can select a period to review and make comments on the violations listed in the Work Hours Review. However, a director must provide the final review and comments.   

To review the work hour violations for the program, the Program Administrator can click the ‘Work Hours Review’ tab, within the Work Hours section.

The Work Hours Review data includes the following:

1. Program name(s)
2. Schedule name (i.e. PGY1-2, PGY3-5)
3. The start date for the review period
4. The end date for the review period
5. The review status (whether or not the Program Director has reviewed the violations)
6. The number of violations for the period
7. The ability to review the violations

The review periods will indicate a status of ‘Unreviewed’ or ‘Partially Reviewed’ until the Program Director reviews the violations, makes comments, places a check mark next to the violation, and then submits the review.

Note: Institutions may include Associate Program Directors in the work hour review period process. If APDs are included, then they will process the work hour review in the same manner as the Program Director.  

Clinical and educational work hours are defined as all clinical and academic activities related to the residency/fellowship program. This includes inpatient and outpatient clinical care, inhouse call, short call, night float and day float, transfer of patient care, and administrative activities related to patient care, such as completing medical records, ordering and reviewing lab tests, and signing orders. For call from home, time devoted to clinical work done from home and time spent in the hospital after being called in to provide patient care count toward the 80-hour weekly limit. Types of work from home that must be counted include using an electronic health record and taking calls. Reading done in preparation for the following day’s cases, studying, and research done from home do not count toward the 80 hours.

Hours spent on activities that are required in the accreditation requirements, such as
membership on a hospital committee, or that are accepted practice in residency/fellowship programs, such as residents’/fellows’ participation in interviewing residency/fellowship candidates, must be included in the count of clinical and educational work hours.

Time residents and fellows devote to military commitments counts toward the 80-hour limit only if that time is spent providing patient care.

[Common Program Requirement: VI.F.1.]

If attendance at the conference is required by the program, or if the resident/fellow is a representative for the program (e.g., presenting a paper or poster), the hours should be included as clinical and educational work hours. Travel time and non-conference hours while away do not meet the definition of “clinical and educational work hours” in the ACGME requirements.

[Common Program Requirement: VI.F.1.]

While it is expected that residents’ and fellows’ schedules will be structured to ensure they are provided with a minimum of eight hours off between scheduled work periods, it is recognized that individual residents or fellows may choose to remain beyond their scheduled time, or return to the clinical site during this time-off period, to care for a patient. The requirement preserves the flexibility for the resident or fellow to make those choices. It is also noted that the 80-hour weekly limit (averaged over four weeks) is a deterrent for scheduling fewer than eight hours off between clinical and education work periods, as it would be difficult for a program to design a schedule that provides fewer than eight hours off without violating the 80-hour rule.
It is important to remember that when an abbreviated rest period is offered under special circumstances, the program director and faculty members must monitor residents/fellows for signs of excessive fatigue.

[Common Program Requirements: VI.F.2.b)-VI.F.2.b).(1)]

The 14-hour time-off period begins when the resident/fellow leaves the hospital, regardless of when the resident/fellow was scheduled to leave.

[Common Program Requirements: VI.F.2.c), VI.F.3.a).(1)]

The requirements specify a 24-hour day off. Many Review Committees have recommended that this day should ideally be a calendar day (i.e., the resident/fellow wakes up at home and has a whole day available). Review Committees have also noted that it is not permissible to have the day off regularly or frequently scheduled on a resident’s/fellow’s post-call day, but understand that in smaller programs this may occasionally be necessary. Note that in this case, a resident/fellow would need to leave the hospital post-call early enough to allow for 24 hours off from clinical and educational work. Because call from home does not require a rest period, the day after home call may be used as a day off.

[Common Program Requirements: VI.F.2.c), VI.F.3.a).(1)]

Residents/fellows who have completed a 24-hour clinical and educational work period may spend up to an additional four hours on site to ensure an appropriate, effective, and safe transition of care (including rounds), to maintain continuity of patient care, and to participate in educational activities such as conferences. During this four-hour period, residents/fellows must not be permitted to participate in the care of new patients in any patient care setting; must not be assigned to outpatient clinics, including continuity clinics; and must not be assigned to participate in a new procedure, such as an elective scheduled surgery. Residents/fellows who have satisfactorily completed the transition of care may attend an educational conference that occurs during this four-hour period.

[Common Program Requirements: VI.F.2.c), VI.F.3.a).(1)]

Programs interested in extending the clinical and educational work hours for specific
rotations for their chief residents can use the “88-hour exception” to request an increase of up to 10 percent in clinical and educational work hours on a program-by-program basis, with endorsement of the Sponsoring Institution’s GMEC and the approval of the Review Committee. If approved, the exception will be reviewed annually by the Review Committee. A request for an exception must be based on a sound educational justification. Most Review Committees categorically do not permit programs to use the 10 percent exception. The Review Committee for Neurological Surgery is currently the only Review Committee that allows exceptions.

[Common Program Requirements: VI.F.4.c)-VI.F.4.c).(2)]

The ACGME specifies that a rotation-specific increase in clinical and educational work hours above 80 hours per week can be granted only when there is a very high likelihood that this will improve residents’/fellows’ educational experiences. This requires that all hours in the extended work week contribute to resident/fellow education. Programs may ask for an extension that is less than the maximum of eight additional weekly hours, and/or for a subgroup of the residents/fellows in the program.

[Common Program Requirements: VI.F.4.c)-VI.F.4.c).(2)]

The hours spent moonlighting are counted toward the total hours worked for the week. No other clinical and educational work hour requirements apply, but the following requirements do:

VI.F.5.a) “Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program, and must not interfere with the resident’s fitness for work nor compromise patient safety.”

VI.B.3.-VI.B.4.c).(2) “The program director, in partnership with the Sponsoring Institution, must provide a culture of professionalism that supports patient safety and personal responsibility. Residents and faculty members must demonstrate an understanding of their personal role in the: provision of patient- and family-centered care; safety and welfare of patients entrusted to their care, including the ability to report unsafe conditions and adverse events; assurance of their fitness for work, including: management of their time before, during, and after clinical assignments; and, recognition of impairment, including from illness, fatigue, and substance use, in themselves, their peers, and other members of the health care team.”

[Common Program Requirements: VI.F.5.a)-c)]

The objectives for allowing the averaging of in-house call (in all specialties except internal medicine) is to offer flexibility in scheduling, not to permit call every other night for any extended length of time, even if done in the interest of creating longer periods of free time on weekends or later in the month. For example, it is not permissible for a resident/fellow to be on call every other night for two weeks straight and then be off for two weeks.

[Common Program Requirement: VI.F.7.]

No. The requirement for one day free every week prohibits being assigned home call for an entire month. Assignment of a partial month (more than six days but fewer than 28 days) is possible. However, keep in mind that call from home is appropriate if service intensity and frequency of being called is low. Program directors are expected to monitor the intensity and workload resulting from home call through  periodic assessment of workload and intensity of in-house activities.

[Common Program Requirement: VI.F.8.a)]

The requirements acknowledge the changes in medicine, including electronic health
records, and the increase in the amount of work residents and fellows choose to do from home. Resident decisions to complete work at home should be made in consultation with the resident’s/fellow’s supervisor. In such circumstances, residents/fellows should be mindful of their professional responsibility to complete work in a timely manner and to maintain patient confidentiality. The requirement provides flexibility for residents/fellows to do this while ensuring that the time spent completing clinical work from home is accomplished within the 80-hour weekly maximum.

[Common Program Requirement: VI.F.1.]

Types of work from home that must be counted include using an electronic health record and responding to patient care questions. Reading done in preparation for the following day’s cases, studying, and research done from home do not count toward the 80 hours. Residents and fellows are expected to track the time spent on these activities and report this time to the program director. The program director then will use this information when developing schedules to ensure that residents and fellows are not exceeding 80 hours per week, averaged over four weeks. Decisions about whether to report brief periods devoted to clinical work (e.g., a phone call that lasts just a couple of minutes) are left to the individual resident or fellow. There is no requirement regarding how this time is tracked and documented and no expectation that the program director assume a role in verifying the time reported by the residents and fellows.

[Common Program Requirements: VI.F.1., VI.F.8.a)]

For call taken from home (home or pager call), the time a resident/fellow spends in the hospital after being called in counts toward the weekly clinical and educational work hour limit. The only other numeric clinical and educational work hour requirement that applies is the one day free of clinical and educational work every week that must be free of all patient care responsibilities, which includes at-home call. Program directors must monitor the intensity and workload resulting from at-home call through periodic assessment of the frequency of being called into the hospital, and the length and intensity of the in-house activities.

When residents/fellows assigned to at-home call return to the hospital to care for patients, a new time-off period is not initiated, and therefore the requirement for eight hours between shifts does not apply. The frequency and duration of clinical work done from home and time returning to the hospital must not preclude rest or reasonable personal time for residents/fellows.

[Common Program Requirements: VI.F.8.a)-b)]

The ACGME expects that clinical and educational work hours in any given four-week period comply with all applicable requirements. This includes months with holidays, during which institutions may have fewer staff members available. During the holiday period, scheduling for the rotation (generally four weeks or a month) must comply with the common and specialty-specific clinical and educational work hour requirements. Further, the schedule during the holidays themselves may not violate common clinical and educational work hour requirements (such as the requirement for adequate rest between clinical and educational work periods), or specialty-specific requirements.

Averaging must occur by rotation. This is done over one of the following: a four-week period; a one-month period (28-31 days); or the period of the rotation if it is shorter than four weeks.

When rotations are shorter than four weeks in length, averaging must be made over these shorter assignments. This avoids heavy and light assignments being combined to achieve compliance.

If a resident/fellow takes vacation or other leave, the ACGME requires that vacation or leave days be omitted from the numerator and the denominator for calculating clinical and educational work hours, call frequency, or days off. The requirements do not permit a “rolling” average, because this may mask compliance problems by averaging across high and low clinical and educational work hour rotations. The rotation with the greatest hours and frequency of call must comply with the common clinical and educational work hour requirements.

The clinical and educational work hour limits of the program in which the resident/fellow rotates apply to all residents/fellows, both those in the program and rotators from another specialty. This expectation also applies when a program has an exception, but it helps to remember that the standard defines the maximum allowable hours, not required hours or hours for all residents/fellows, so that it is always possible to work fewer hours than the limit.