Clinical and Educational Work Hours Policy

Policy Statement 

The following policy applies to all Graduate Medical Education training programs sponsored by the University of Minnesota Medical School, both ACGME-accredited and non-accredited, and to all Graduate Medical Education trainees when assigned to any other institution or clinical site as part of their training program.

All programs are required to adhere to and monitor compliance of their trainees with the ACGME clinical and educational work hours standards as outlined in the ACGME Common Program Requirements. Training programs must also follow program-specific guidelines as outlined by their individual Review Committees. The sponsoring institution monitors training program adherence to the clinical and educational work hour requirements.

Management of clinical and educational work hours is a shared responsibility of programs and trainees.  The trainees must adhere to the policy and report violations. The program must structure clinical activities to adhere to, monitor and enforce compliance with the requirements. The institution must provide oversight to the programs and address non-compliance.

Reason for Policy 

The purpose of this policy is to define clinical and educational work hour requirements for Graduate Medical Education trainees, define oversight and monitoring for compliance with the regulations, and define the responsibilities of the trainees, the programs, and the sponsoring institution. 

Definitions

Clinical and Educational Work Hours 

Time spent at the worksite performing clinical and/or academic activities required by the trainee’s GME training program, including: 

  • Patient care activities, both inpatient and ambulatory, whether scheduled or not. 
  • Administrative activities that are related to patient care. 
  • In-hospital “on call”, regardless of what the trainee activities are during such periods. 
  • Scheduled academic activities. 
  • Time spent on direct patient care activities and in-hospital during home call.
  • Time spent moonlighting, if allowed.

Trainee Responsibilities

Trainees are responsible for adhering to the schedule created by their programs to provide both educational and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities. Trainees have a personal role in accurately reporting their clinical and educational work hours. Trainees that are at risk of violating work hour rules have an obligation to inform program leadership so that coverage can be arranged to avoid violation.

Trainees are required to report the following work activities and all work hour violations to their program leadership for review and process improvement.

  • Patient care:
    • Inpatient and outpatient care occurring at the hospital or while at home.
    • Administrative duties related to patient care occurring at the hospital or while at home.
    • Electronic Medical Record (EMR) note writing, preparation of discharge summaries, phone calls related to patient care, while at home or at the training site.
    • The provision for transfer of patient care and sign-outs.
    • Time spent in-house during call activities.
  • Education/Academic:
    • Scheduled academic activities such as conferences or unique educational events.
    • Research.
    • Time spent at academic conferences and meetings when attendance is required by the program, or when the trainee is acting as a representative of the program. Only actual meeting time counts towards work hours.
    • Work hours spent on activities that are required by the accreditation standards or that are accepted practice in training programs.
  • The following activities are excluded from work hour reporting:
    • Academic preparation time.
    • Travel and non-conference time when at a conference or meeting.

Concerns about continuous work hour violations not adequately addressed by their program can be reported to the Designated Institutional Official at [email protected]. Anonymous reporting of work hour violations can occur via a Qualtrics form. Trainees may also report violations directly to the ACGME.

Program Responsibilities

Programs are responsible for knowing the clinical and educational work hours requirements set forth in the ACGME Common Program Requirements and in their program-specific requirements. 

  • Programs must design an effective program structure that is configured to provide trainees with educational and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities, within the bounds of ACGME requirements. 
  • Each program is required to have a written clinical and educational work hours policy consistent with this Institutional Policy. Specific night float requirements should be articulated in this policy as well as any exemptions if they are approved by the Review Committee.
  • The program's clinical and educational work hours policy and trainee relief procedures must be communicated to all members of the faculty and trainee staff.
  • Programs must implement a system to monitor compliance with clinical and educational work hour requirements and outline the protocol in their Program Manual. 
  • Programs must report work hour violations to the GME office quarterly and articulate a process for addressing those violations.
  • Programs must provide alternative coverage for a trainee’s clinical responsibilities if the trainee is too fatigued to continue their assigned clinical responsibilities. 

Sponsoring Institution Responsibilities

Oversite

  1. The Sponsoring Institution must oversee clinical and educational work hours across all programs and address areas of non-compliance in a timely manner. The Graduate Medical Education office will review work hour violations as reported by programs quarterly and partner with programs to address non-compliance or concerning trends.
  2. The Sponsoring Institution must oversee systems of care, learning and working environments, and education programming that facilitate fatigue mitigation for trainees. In partnership with training programs, the Sponsoring Institution must ensure safe, quiet and private sleep facilities and safe transportation options for trainees who may be too fatigued to safely return home.

History

November, 2019: Revised for consistency with ACGME Institutional Requirements and ACGME Common Program Requirements.

January 2003: Approved by Graduate Medical Education Committee

Appendix

  1. Policy Implementation
    1. Program Implementation Timeline
      • January 1, 2020: Programs are expected to develop a program level policy and process to comply with the revised GME policy and list their program policy in their program manual.
      • January 31, 2020: Programs must communicate the new policy and monitoring process to their residents or fellows and implement their plan.
    2. Graduate Medical Education Implementation Timeline
      • April 1, 2020: GME Administration emails a quarterly survey to programs asking them to certify that quarterly work hours (for period 1/1/2020 - 3/31/2020) have been reviewed and that violations have been addressed.
      • April 30, 2020: Programs complete the survey by this date.
      • May 1, 2020 to mid May 2020: GME Administration analyzes and reviews program responses to the survey. GME prepares the data to present to the GMEC.
      • May, 2020 (4th Tuesday): GME Administration presents data to the GMEC and shares the data with the respective programs and departments.
  2. Policy Monitoring
    1. Program Policy Monitoring: Example Methods 
      • Send out a monthly survey to residents or fellows for all of their rotations (sample survey)
      • Send out a survey quarterly to track low risk rotations
      • Do biopsy monitoring of all learners for a particular time frame (sample biopsy form)
      • Do biopsy monitoring of learners only on high risk rotations
      • Use RMS to conduct daily monitoring of high risk rotations
    2. Graduate Medical Education Monitoring
    3. Oversight
      • GME will compare the quarterly hours attestation with the trainee surveys (Annual Program Evaluation and the ACGME Annual Resident Fellow Survey.) Discrepancies must be explained by the program.
  3. Reporting
    1. Trainee Reporting Survey

Resource List

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Clinical
Work Hours
ACGME