Department of Medical Education
GE 8

INTRODUCTION: Advocate Illinois Masonic Medical Center is committed to providing residents with a sound academic and clinical education carefully planned and balanced with concerns for patient safety and resident well being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Duty hour assignments must recognize that faculty and residents collectively have responsibilities for the safety and welfare of patients. Programs must assure that residents are provided with appropriate back-up support when patient care responsibilities are especially difficult or prolonged.

Procedure

1. Each residency program will have a policy regarding duty hours and on call scheduling for residents that complies with the ACGME institutional guidelines as well as other respective accreditation bodies as applicable. These policies must be approved by the Education and Research Committee/GMEC and distributed to all faculty members and to all residents.
2. Residents must be provided with at least, one day out of seven free from all educational and clinical responsibilities, averaged over a four week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational and administrative activities.
3. Residents must not be scheduled to be on in-house call more frequently than every third night, averaged over a four week period.
4. Residents must not work more than 80 hours per week, averaged over a four week period, inclusive of all in-house call activities.
5. There is 24-hour limit on on-call duty, with an added period of up to 6 hours for continuity and transfer of care, educational debriefing and didactic activities; no new patients may be accepted after 24 hours.
6. A 10-hour minimum rest period must be provided between duty periods.
7. When residents take call from home and are called into the hospital, the time spent in the hospital must be counted toward the weekly duty hour limit.
8. Time spent in patient care activities external to the educational program (moonlighting) that occur at AIMMC or one of its sites count toward the duty hour limit.
9. The Program Director is responsible for monitoring compliance with the duty hours requirements, including:
   1. obtaining data on adherence to duty hours policies with frequency sufficient to ensure compliance; a minimum of two times per year
   2. recertifying to the Education and Research Committee/GMEC in assigned periodic reports each year that the program is in compliance with the duty hour policies.
10. The DIO and/or Director of Medical Education are also responsible for monitoring compliance with the duty hours requirements by:
    1. meeting with residents and discussing their experiences with them;
    2. Obtaining anonymous feedback on duty hours on a yearly questionnaire to residents;
    3. Reviewing and endorsing the individual Program information submitted on the annual ACGME Duty Hour Survey
    4. Providing information on compliance with duty hours to the governing council and medical staff based on the results of the residents' feedback and the yearly certification by the program directors.

The definition of some of the resident duty hours terms used in this policy are listed in the "Glossary of Terms Related to Resident Duty Hours."

Additional clarification of the duty hours policies can be found in the "Frequently-Asked Questions about the Proposed ACGME Common Duty Hour Standards."

Approved by Education and Research Committee 06/20/01
Revised by Education and Research Committee 06/18/03
Revised by Education and Research Committee 08/03/05

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