Tips for monitoring resident work hours

Residency Program Insider, October 23, 2007

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ACGME defines resident duty hours as all clinical and academic activities related to the program-for example, patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. However, some programs, such as emergency medicine, have more stringent rules.


Monitoring and enforcing duty hour restrictions are a shared responsibility among the sponsoring institution, the program, the faculty, and the residents. The institution is required to have formal written policies and procedures regarding work hour supervision for its programs, faculty, residents, and clinical staff.


Your program should not only comply with the institutional duty hours policy, but it should also understand all of the nuances in regards to its specialty. For example, some programs have different interpretations of "a new patient" in terms of what new patients a resident is able to provide care for during the six additional hours following a 24-hour work period. 


Beyond duty hours alone, programs have an obligation to educate residents and faculty on issues about fatigue, including about how to recognize and manage it.


Faculty members need to be "on board" with the rules and not subvert these policies, intentionally or unintentionally. Faculty physicians do not have a work hour limit, however, so the program may need to be mindful of faculty fatigue as well, especially because some of the faculty may not be able to recover sleep as well as (usually) younger residents.


Residents have to share in duty hours too. They have to be willing to recognize when they or their colleagues are close to going over the hours and what measures they must take in their personal lives to make certain they come to work rested. If residents believe they can't leave on time without putting patient care at risk, they must discuss these situations with their faculty and program director. They must protect their out-of-work time to make sure they get the rest they need.


Although ACGME does not specifically require a monitoring system for duty hours, you probably want to monitor periodically-either informally or formally-to ensure your residents are complying with the work hour requirements. Consider having an early warning system in place that will allow you to recognize whether there are certain rotations or times of the year when residents aren't able to comply; then problem solve to proactively plan what can be done about these instances.


A good way to start may be with once yearly surveys or resident focus groups. If you identify a problem, you can institute more frequent monitoring. Keep in mind that you don't want to make more work for residents by instituting a cumbersome process to report duty hours. Determine whether you can replace any system you currently use with an easier system. Some programs use swipe card technology to have residents clock in or clock out; others "count" when the resident first logs into a hospital workstation and logs out again. Some programs track hours using the times residents enter and exit the garage. Although these systems may run the risk of overestimating hours, they are advantageous in that they don't depend on a resident doing anything "extra" to track their hours.


There are several proprietary programs that will track duty hours as well. For example, many tracking programs are built into more complex programs on resident scheduling and evaluations. Other programs are designed primarily for duty hours tracking, such as


Be aware that you can also "over survey" your residents and precipitate survey behavior that isn't constructive. {You don't want your residents to just write down "79.9" hours just because they don't want to be bothered with filling out a time card, even though they are going over the 80 hours limit.)


Editor's Note: The paragraphs above are excerpted from HCPro's recently published training resource for residency program directors and coordinators, Insider's Guide to the ACGME Site Visit, Second Edition, by Kathryn Andolsek, MD, MPH, and Shep Cohen.

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