Applies to: WSU Elson S. Floyd College of Medicine Graduate Medical Education (GME) Sponsoring Institution and all accredited post-graduate medical training programs (i.e. residency or fellowship) and non-accredited clinical fellowship programs sponsored by the College of Medicine.
Date: August 15, 2023
1.0 Policy Statement
It is the WSU College of Medicine GME policy to maintain a clinical and educational work hour policy to ensure effective oversight of institutional and program-level compliance with ACGME clinical and educational work hour requirements.
2.0 Definitions
Clinical Education Work Hours (Duty Hours)
All clinical and academic activities related to the program: patient care (inpatient and outpatient); administrative duties relative to patient care; the provision for transfer of patient care; time spent on in-house call; time spent on clinical work done from home; and other scheduled activities, such as conferences. These hours do not include reading, studying, research done from home, and preparation for future cases.
Trainee
A physician in training at an ACGME accredited graduate medical education program, the term includes Interns, Residents, and Fellows or other trainee enrolled in an educational program whose education falls under the purview of the WSU College of Medicine Office of Graduate Medical Education.
3.0 Responsibilities
GMEC and DIO
4.0 Procedures
Each training program 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. Each program must track clinical and educational work hours in compliance with the ACGME and WSU GME policies. It is the responsibility of each Trainee, and faculty member, to ensure that he/she is in compliance with clinical and educational work hour requirements. Programs are required to use the Resident Management System to monitor Trainee work hours.
All sponsored training programs must
- Educate all faculty members and residents:
- To recognize the signs of fatigue and sleep deprivation, in alertness management and fatigue mitigation processes.
- To identify high risk units or service areas specific to the Program’s rotations and develop fatigue management strategies
- To identify processes to ensure continuity of patient care in the event that a Trainee is unable to perform his/her duties.
- To provide sleeping /call rooms for Trainees during in-house-call, or for napping or sleep post call prior to driving home.
- To educate Trainees and Faculty as to the site and/or Program specific transportation options available to Trainees who are too fatigued to safely return home post shift or post call (see GME Safe Transportation Home Policy)
- To require all Trainees to track work hours using the Resident Management System
Specific requirements for work hours related to clinical experience and education are set by the ACGME in the Common Program Requirements. For these specifics, refer to the Common Program Requirements on the GME website. The requirements include limitations on:
- Maximum clinical and educational work hours per week
- Mandatory time free of clinical work and education
- Maximum clinical work and education period length
- Moonlighting
- In-house night float
- Maximum in-house on-call frequency
- At-home call
All Trainees are expected to follow these ACGME requirements and truthfully report actual hours worked in the Resident Management System. Any violations, including potential violations, must be explained using the Resident Management System.
The Program Director must regularly monitor Trainee compliance with established work hour guidelines. The resident management system (MedHub, New Innovations) should alert the Program Director of violations and record of review.
GMEC reviews each Sponsored Program’s work hour compliance during each GMEC meeting and at the annual program evaluation review.
5.0 Related Policies
GME Moonlighting Policy
6.0 Revision History
GMEC Approval: May 10, 2018
Revision/Review Date(s): April 21, 2020, August 15, 2023
Responsible Office: WSU College of Medicine Sponsoring Institution
Policy Contact: Designated Institutional Official
Supersedes: N/A