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Institutional Duty Hour Policy

The GMEC ensures that the institution and individual training programs remain in compliance with all ACGME Common Program Requirements and Residency Review Committee (RRC) Duty Hour Requirements:

1.  Resident work hours must not be excessive.  The structuring of duty hours and schedules must focus on the needs of the patient, continuity of care and the educational needs of the residents.  Duty hours will be consistent at all times with ACGME requirements.  The Program Director is responsible for monitoring resident activities to ensure that resident fatigue does not contribute to diminished learning or detract from patient safety.  

2.  The educational goals and objectives of the program and the resident learning objectives must not be compromised by excessive reliance on residents to fulfill non-physician service obligations.  (Non-physician service obligations are defined by the ACGME as those duties which in most institutions are performed by technologists, aides, transporters, nurses or other categories of health care workers.)

3.  GMEC will oversee the education of all faculty members and residents to recognize the signs of fatigue and sleep deprivation, alertness management and fatigue mitigation processes and ensure that programs adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, including a process to ensure continuity of patient care in the event that a resident may be unable to perform his/her patient care duties. Adequate sleep facilities and/or safe transportation options will be made available for residents who may be too fatigued to safely return home. 

4.  All incoming residents will be provided with written information on ACGME duty hour rules.

5.  This policy shall apply to residents and fellows in both accredited and non-accredited training programs.

6.  Compliance with this Duty Hour Policy will be monitored in the following ways:

     a. New Innovations Duty Hour Violation Reports can be generated at any time by each program to assist in monitoring resident and fellow duty hours. The Office of Graduate Medical Education will regularly generate reports for all residents and fellows for review by the GMEC.

     b. Residents may report concerns related to duty hours by completing and submitting a confidential duty hour complaint via the Graduate Medical Education web site, or by contacting the Designated Institutional Officer (DIO) or their delegate on the House Staff Board of Directors.

     c. Any reports of concerns related to duty hours or excessive institutional service obligations (scut work) will be promptly addressed with the program so that compliance can be assured at all times.

     d. End of year evaluation will address work hour issues.

 Last Approval Date:  January 20, 2017

 Effective Date: January 20, 2017