Medical College of Wisconsin Affiliated Hospitals, Inc.
Institutional Policy
DUTY HOURS FOR HOUSESTAFF
PURPOSE
The purpose of this policy is to outline the duty hour requirements for all MCWAH Programs, describe how MCWAH will monitor Program compliance with ACGME duty hour standards and outline the process for requesting a duty hour exception.
POLICY
1. Programs are required to comply with all duty hour standards outlined in the ACGME Common Program Requirements as well as those further specified by the Specialty/Subspecialty Residency Review Committee (RRC).
2. Housestaff must record their duty hours in the New Innovations Residency Management Suite (NI). Programs must utilize and properly configure the NI Block Schedule Module and Duty Hours Module for this purpose. An exception to this requirement may be made by the Designated Institutional Official (DIO) for sufficient reason.
3. Programs are required to monitor housestaff duty hours on a regular basis throughout the year.
4. MCWAH will monitor housestaff compliance with ACGME duty hour standards by analyzing the duty hour data from each program at least twice a year. These results will be shared with the Graduate Medical Education Committee (GMEC).
5. An ACGME RRC may grant exceptions for up to 10% of the 80-hour limit to individual programs based on a sound educational rationale. Each RRC will indicate in the specialty specific requirements whether they will consider requests for exceptions to the 80-hour per week limit. A request for a duty hour exception may be made if a program can demonstrate and document that such an exception is necessary for educational reasons and critical to meet patient care needs. The following procedure will be used:
A. DIO REVIEW. The Program Director will submit a written request for a duty hour exception to the DIO. The written request must include the following documentation:
1) Patient Safety: Information must be submitted that describes how the program and institution will monitor, evaluate, and ensure patient safety with extended housestaff work hours.
2) Educational Rationale: The request must be based on a sound educational rationale which should be described in relation to the program's stated goals and objectives for the particular assignments, rotations, and level(s) of training for which the increase is requested. Blanket exceptions for the entire educational program should be considered the exception, not the rule.
3) Moonlighting Policy: Specific information regarding the program's moonlighting policies for the periods in question must be included.
4) Call Schedules: Specific information regarding the housestaff call schedules during the times specified for the exception must be provided.
5) Faculty Monitoring: Evidence of faculty development activities regarding the effects of housestaff fatigue and sleep deprivation must be appended.
6) The current accreditation status of the program.
B. GMEC REVIEW AND APPROVAL. If the DIO determines that the program's request is warranted and it has adequately documented the need, the DIO shall submit the request to the GMEC for discussion and approval. If the GMEC approves the request for a duty hour exception, the DIO will produce a documented written statement of institutional endorsement of the requested duty hour exception. This document shall be signed by the DIO.
C. SUBMISSION OF REQUEST TO THE RRC. If approved by the GMEC, the program will submit the required information to its RRC. The RRC may judge that such a request cannot be considered without a site visit. If approved, the maximum duration of the approval may not exceed the length of time until the program's next review. The written request to the RRC shall include:
1) All items in A.1) – 6) above.
2) The written GMEC endorsement of the request for a duty hour exception signed by the DIO.
3) A copy of MCWAH's written procedures and criteria for endorsing requests for an exception to the duty hour limitations (this policy).
4) Documentation of MCWAH's accreditation status.
6. Programs are required to comply with MCWAH’s written policy on moonlighting. See the MCWAH Moonlighting policy.
7. Programs are required to comply with MCWAH’s written policy on housestaff fatigue. See the MCWAH Housestaff Fatigue policy.
This revised policy was approved by the MCWAH Graduate Medical Education Council on July 18, 2011. The original policy was approved on September 17, 2007. This policy replaces the following policies: the Housestaff Duty Hour policy approved May 1998 (revised May 2003 and August 2010), the Monitoring of Duty Hour policy approved February 2005, and the Process for a Duty Hours Exception Request policy approved August 2010.