Policies / Institutional Clinical and Educational Work Hours Policy

Date Established: 03/08/2007

Revision History: 08/14/08, 10/08/09, 11/12/09, 01/13/11, 10/13/11, 11/16/12, 9/14/17, 5/13/21, 06/09/22

Policy Reviewers: GME Office, Policy Subcommittee, UW Graduate Medical Education Committee (GMEC)

All UW residencies and fellowships accredited by the Accreditation Council for Graduate Medical Education (ACGME) and sponsored by the UW School of Medicine, and non-ACGME fellowships that fall under ACGME recognition of non-standard training (NST) programs for J-1 visa sponsorship.

NOTE: Requirements for non-standard (NST) programs are annotated where applicable. An NST program is defined as clinical training for foreign national physicians in advanced subspecialty programs for which there is no ACGME accreditation or American Board of Medical Specialties (ABMS) Member Board certification. An NST trainee is a fellow in an NST program who holds a J-1 visa sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG).

The purpose of this policy is to ensure effective oversight of institutional and program-level compliance with ACGME clinical and educational work hour requirements. It further sets the expectation that programs must comply with clinical and educational work hour requirements to create a clinical learning environment that promotes the best outcomes for patients, and the well-being of trainees and faculty members.

3. Definitions

• Clinical and Educational Work Hours: 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.

4. Policy

Programs, in partnership with the Sponsoring Institutions, must design an effective program structure that is configured to provide residents with educational and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities. (ACGME Common Program Requirements (CPR) 6, preface) Programs must meet the following requirements:

A. Maximum Hours of Clinical and Educational Work per Week:

Work hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting. (CPR 6.20.; NST Recognition Requirements 2.6).

NOTE: The ACGME does not allow compliance with work hour limits to be based on a rolling average. Averaging must be by rotation, aggregated over a four-week period for rotations of one calendar month or longer, or calculated within the duration of the rotation for rotations of less than four weeks in length. Compliance with all aspects of work hour limits must be achieved within a given rotation, regardless of duration (i.e., a two-week rotation of heavy duty and a two-week rotation of light duty may not be combined to achieve compliance). Further, vacation or leave days must be taken out of the numerator and the denominator for calculating work hours, call frequency or days off (i.e., if a resident is on vacation for one week, the hours for that rotation should be averaged over the remaining three weeks).

B. Mandatory Time Free of Clinical Work and Education:

Residents should have eight hours off between scheduled work periods. (CPR 6.21) There may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80-hour and the one-day-off-in-seven requirements. (CPR 6.21.b.)

Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call. (CPR 6.21.a.)

Residents must be scheduled for a minimum of one day in seven free of clinical work and required education (when averaged over four weeks) (CPR 6.21.d.; NST Recognition Requirements 2.7.). At-home call cannot be assigned on these free days. (CPR 6.21.b). At- home clinical responsibilities cannot be assigned on these free days for trainees in NST programs. (NST Recognition Requirements 2.7.)

C. Maximum Clinical Work and Education Period Length:

Clinical and education work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments (CPR 6.2). Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident education (CPR 6.22.a.) Additional patient care responsibilities must not be assigned to a resident during this time. (CPR 6.22.a.)

D. Clinical and Educational Work Hour Exceptions:

In rare circumstances, after handing off all other responsibilities, a resident, on their own initiative, may elect to remain or return to the clinical site in the following circumstances: to continue to provide care to a single severely ill or unstable patient, or humanistic attention to the needs of a patient or family, or to attend unique educational events. (CPR 6.23) These additional hours of care or education will be counted toward the 80-hour weekly limit. (CPR 6.23.a.)

E. In-House Night Float:

Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements. (CPR 6.26) The maximum number of consecutive weeks of night float, and maximum number of months of night float per year may be further specified by the Review Committee.

F. Maximum In-House On-Call Frequency:

Residents must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period). (CPR 6.27)

NOTE: Internal Medicine residency program must not average in-house call over a four-week period.

G. At-Home Call

Time spent on patient care activities by residents on at-home call must count towards the 80-hour maximum weekly limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one day in seven free of clinical and education, when averaged over four weeks. (CPR 6.28.)

At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident. (CPR 6.28.a)

Residents are permitted to return to the hospital while on at-home call to provide direct care for new or established patients. These hours of inpatient care must be included in the 80-hour weekly maximum. (CPR 6.23.a)

5. Fatigue Mitigation

Programs must educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation; educate all faculty members and residents in alertness management and fatigue mitigation processes; and, encourage residents to use fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning. (CPR 6.15) Each program must ensure continuity of patient care, consistent with the program’s policies and procedures referenced in 6.19, in the event that a resident may be unable to perform their patient care responsibilities due to excessive fatigue. (CPR 6.14.a.) The program, in partnership with the UW School of Medicine, must ensure adequate sleep facilities and safe transportation options for residents who may be too fatigued to safely return home. (CPR 6.16)

All residents are required to complete an online module on Physician Well-Being via the UW Medicine Learning Hub, or other GME-approved training arranged by their department, which will fulfill this training requirement. Programs may provide additional training to residents and must identify proper training methods for their faculty.

6. Moonlighting

The UW School of Medicine has established a Moonlighting and Outside Work Policy to address moonlighting activities. 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. (CPR 6.25)

1. Time spent by residents in internal and external moonlighting (as defined in the ACGME Glossary of Terms) must be counted toward the 80-hour maximum weekly limit. (CPR 6.25.a)
2. PGY-1 residents are not permitted to moonlight. (CPR 6.25.b)

7. Program Policies

The UW School of Medicine requires all ACGME-accredited residency and fellowship training programs and all NST programs to develop and maintain a policy on resident work hours. Program policies must meet the educational objectives and patient care responsibilities of the training program, and must comply with work hour limits according to specialty-specific Program Requirements, the Common Program Requirements, the NST Recognition Requirements, and the Institutional Clinical and Educational Work Hours Policy. In addition, the policy must also address:

1. How the program monitors work hours, according to UW institutional policies, with a frequency sufficient to ensure compliance with ACGME requirements.
2. How residents will record work hours spent on clinical activities while on home call.
3. Protocols for adjusting schedules as necessary to mitigate excessive service demands and/or fatigue.
4. How the program monitors the demands of at-home call and protocols for adjusting schedules as necessary to mitigate excessive service demands, if applicable.
5. How the program monitors the need for and ensures the provision of back up support systems when patient care responsibilities are unusually difficult or prolonged.
6. Mechanisms used by the program to ensure residents report their work hours (including program assigned work hours, and moonlighting activities, if applicable) in MedHub.

The work hour policy of the program in which the resident rotates apply to all residents, both those in the program and rotators from another specialty.

Records of program’s work hours policies are maintained by the GME Office in MedHub.

8. Compliance

The UW School of Medicine monitors compliance with clinical and educational work hour limits through the MedHub Residency Management System. All residents are required to track their work hours using MedHub, and have access to two-week blocks for documenting their time for the prior and current weeks. Blocks are available on a one-week rolling cycle (Sunday – Saturday), after which residents will be locked out from reporting work hours. Residents approved for internal and external moonlighting activities are also required to report all moonlighting hours worked in MedHub.

Clinical and educational work hour limits and submission rates must be monitored by each program. The Graduate Medical Education Committee (GMEC) will monitor submission rates monthly, and clinical and educational work hour limits quarterly. Programs found not in compliance with the work hour limits for three months within a six-month period, or with the reporting requirements (less than 80% of shifts reviewed) may be asked to submit a corrective action plan to GMEC. Instances of non-compliance identified by GMEC are considered when determining recommendations for Special Review. Questions or concerns with the data reported should be brought to the immediate attention of the GME Office to ensure any reporting errors are addressed in a timely manner.

9. Reporting Concerns

Residents are encouraged to contact the GME Office anonymously or confidentially to report work hour violations through the GME Report a Concern form. The program director will be required to submit a corrective action plan to GMEC within 30 days of receipt of the complaint.