DUTY HOURS AND WORKING ENVIRONMENT POLICY FOR AVA-TRAINEES PURPOSE The purpose of this policy is to identify the responsibilities associated with Duty Hours for program directors, trainees, and the Institution. POLICY STATEMENT It is the policy of The University of Texas MD Anderson Cancer Center (MD Anderson) to ensure that trainee Duty Hours promote an environment that provides high-quality education and safe and effective patient care while promoting the well being of clinical trainees. SCOPE This policy covers all Graduate Medical Education (GME) and Clinical Health Professions (CHP) training programs at MD Anderson. Compliance with this policy is the responsibility of all faculty, trainees/students, and other members of MD Anderson s workforce. TARGET AUDIENCE The target audience for this policy includes, but is not limited to, faculty and staff associated with MD Anderson s GME programs as well as the students and trainees enrolled in those programs. DEFINITIONS Continuous Time on Duty: The period that a clinical trainee is in the hospital continuously, counting the trainee s regular scheduled day, time on call, and the hours the trainee remains on duty after the end of the on-call period to transfer the care of the patient and for didactic activities. Duty Hours: All clinical and academic activities related to the clinical training program, including patient care (both in-patient and out-patient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences and research activities. Duty Hours do not include reading and preparation time spent away from the duty site. Moonlighting hours must be counted in the duty hour policy. (For detail, see Duty Hours section below). Home Call (Pager Call): Scheduled patient care assignments beyond the normal workday that are taken from outside the assigned institution. It generally involves trainees providing coverage to a population of Page 1 of 9
patients from their home, with the expectation that they may need to come into the hospital upon being called, or via the telephone direct trainees or other health professionals in providing patient care. In-House Call: Scheduled patient care assignments beyond the normal workday where trainees are required to be immediately available in the assigned institution (generally from evening until the next morning). Moonlighting: Patient care activities external to the educational program that trainees engage in at sites used by the educational program ( in-house moonlighting) and other clinical sites. New Patient: Any patient for whom the trainee has not previously provided care. On-Call Activities: The objective of on-call activities is to provide trainees with continuity of patient care experience throughout a 24-hour period. PROCEDURE FOR GME PROGRAMS 1.0 Program Directors Program directors are responsible for: 1.1 Establishing and distributing duty schedules that meet the standards. A. Duty Hours: Duty Hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all In-House Call activities. Trainees must be provided with one day in seven free from all educational, clinical, and administrative responsibilities, averaged over a 4-week period, inclusive of On-Call Activities. One day is defined as one continuous 24-hour period. This standard does not include Moonlighting activities. Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after In-House Call. This standard does not include Moonlighting activities. Continuous on-site duty, including In-House Call, must not exceed 24 consecutive hours. Trainees may remain on duty up to six additional hours to participate in didactic activities, transfer of patients, conduct outpatient clinics, or maintain continuity of medical and surgical care. This standard does not include Moonlighting activities. The program director must ensure that Moonlighting does not interfere with the ability of the trainee to achieve goals and objectives of the educational program. The program director must comply with institutional policies and procedures regarding Moonlighting. Page 2 of 9
B. On-Call Activities: In-House Call must occur no more frequently than every third night, averaged over a four-week period. Continuous on-site duty, including In-House Call, must not exceed 24 consecutive hours. Trainees may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in accreditation agency or institutional requirements. No New Patients may be accepted after 24 hours of continuous duty. The frequency of at-home call is not subject to the every-third-night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each trainee. Trainees taking at-home call must be provided with one day in seven completely free from all educational and clinical responsibilities, averaged over a four-week period. When trainees are called in to the hospital from home, the hours trainees spend inhouse are counted toward the 80-hour limit. Moonlighting that occurs within the clinical training program, the sponsoring institution, or the non-hospital sponsor s primary clinical site (i.e., internal Moonlighting) must be counted toward the 80-hour weekly limit on Duty Hours. 1.2 Oversight of Duty Hours and working environment is to ensure quality education, patient safety, and trainee well being. Each program must have written policies and procedures consistent with institutional requirements for trainee Duty Hours and the working environment. These policies must be distributed to the trainees and the faculty, and ensure the following: A. Duty-hour assignments that recognize that faculty and trainees collectively have responsibility for patient safety and welfare. B. Schedules for teaching staff structured to provide ready supervision and faculty support/consultation to trainees on duty. C. Monitoring of trainees for the effects of sleep loss and fatigue by the program director and faculty, with appropriate action when it is determined that fatigue might affect safe patient care or learning. D. Education of faculty and trainees in recognizing the signs of fatigue and applying preventive and operational counter measures. E. Monitoring the demands Home Call places on trainees and make adjustments, as necessary, to address excessive demands and fatigue. F. Back-up support systems when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create trainee fatigue sufficient to jeopardize patient care. G. Monitoring of Duty Hours with frequency sufficient to ensure an appropriate balance between service and education. Duty Hours must also be monitored to ensure that time scheduled on duty and actual time worked meet the standards as outlined above. H. Faculty and trainees are aware of their duty hour reporting obligations. Page 3 of 9
2.0 Institution The Institution is responsible for: 2.1 Monitoring program policies governing trainee Duty Hours. 2.2 Requiring a sound educational justification of any increases above the 80 hours. 2.3 Submitting an annual report to the sponsoring institution s governing body on duty hour compliance. 2.4 Establishing Institutional policies on patient care activities external to the educational program ( Moonlighting ), prospective approval of these activities, and monitoring their effect on performance in the educational program. 2.5 Requiring programs and their sponsoring institutions to have policies and procedures to monitor and support the physical and emotional well being of trainees. 2.6 Requiring sponsoring institutions to monitor the demands Home Call places on trainees in all programs, and making adjustments, as necessary, to address excessive demands and fatigue. 2.7 Providing patient care support services for IV, phlebotomy, and transport activities to reduce trainee time spent on routine activities. 3.0 Trainee The trainee is responsible for: 3.1 Participating fully in all aspects of their training. 3.2 Providing accurate documentation of actual hours worked via the authorized web-based tracking system as required by institutional and program policy in a timely fashion. 3.3 Reporting problems with Duty Hours, schedules, or actual time worked as soon as possible to the program director or institutional personnel. 4.0 Duty Hours and Working Environment Procedures 4.1 Duty Hours Monitoring: On a quarterly basis, the GME office will report any noncompliance to Program Directors. The office utilizes a standard reporting tool across all programs to track data relating to both reporting compliance and Duty Hours violations. 4.2 Duty Hours Exceptions Program: A. The Graduate Medical Education Committee (GMEC) may grant exceptions for up to ten percent (10%) of the 80-hour limit to individual programs based on sound educational rationale. All hours in the requested extended work week must contribute to the trainees education. The Designated Institutional Official (DIO) or the Chair of the GMEC must sign GMEC approval of the extended workweek. B. The program must submit a request for extended Duty Hours to the GMEC by submitting the request packet to Office of Graduate Medical Education. The proposal must specify Page 4 of 9
the assignments, rotations, training levels, and duration for which the exception is requested. The proposal to the GMEC must contain the following documentation: Patient Safety: Information must be submitted that describes how the program will monitor, evaluate, and ensure patient safety with extended trainee work hours. Educational Rationale: The request must be based on a sound educational rationale that 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 will be considered the exception, not the rule. Moonlighting Policy: Specific information regarding the program s Moonlighting policies for the periods in question must be included. Call Schedules: Specific information regarding trainee call schedules during the times specified for the exception must be provided. 4.3 GMEC: Faculty Monitoring: Evidence of faculty development activities regarding the effects of trainee fatigue and sleep deprivation must be appended. A. The GMEC will: Formally review proposals at its regular monthly meetings and will retain documentation of its actions in the program s history and in the committee minutes; Judge whether the request justifies granting approval of the extension of the maximum weekly number of Duty Hours from 80 up to 88 hours, averaged over four (4) weeks; Specify the assignments and level(s) of training to which the proposal applies if the requested exemption is granted; Stipulate the duration of the exception, which will be no longer than the next internal review of the program; Monitor and re-evaluate the education purpose for the exception at the end of the initial year; and Re-evaluate the patient safety aspects and educational rationale for the exception at the time of each internal review and may continue, deny, or modify the exception. B. In the event that the GMEC denies a request, the action cannot be appealed. PROCEDURE FOR CHP PROGRAMS 1.0 Program Directors Program directors are responsible for: Page 5 of 9
1.1 Establishing and distributing duty schedules that meet the standards as set by their oversight agencies. On-Call Activities consist of continuous on-site duty, including In- House Call, and must not exceed 24 consecutive hours. 1.2 Oversight of Duty Hours and working environment to ensure quality education, patient safety, and trainee well being. Each program must have written policies and procedures consistent with institutional requirements for trainee Duty Hours and the working environment. These policies must be distributed to the trainees and the faculty and ensure the following: A. Duty-hour assignments that recognize that faculty and trainees collectively have responsibility for patient safety and welfare. B. Schedules for teaching staff structured to provide ready supervision and faculty support/consultation to trainees on duty. C. Monitoring of trainees for the effects of sleep loss and fatigue by the program director and faculty, with appropriate action when it is determined that fatigue might affect safe patient care or learning. D. Education of faculty and trainees in recognizing the signs of fatigue and applying preventive and operational counter measures. E. Back-up support systems when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create trainee fatigue sufficient to jeopardize patient care. F. Monitoring of Duty Hours with frequency sufficient to ensure an appropriate balance between service and education. Duty Hours must also be monitored to ensure that time scheduled on duty and actual time worked meet the standards as outlined above. 2.0 Institution The Institution is responsible for: 2.1 Monitoring program policies governing trainee Duty Hours. 2.2 Submitting reports as required by oversight agencies to the sponsoring institution s governing body on duty hour compliance. 2.3 Establishing Institutional policies on patient care activities external to the educational program ( Moonlighting ), prospective approval of these activities, and monitoring their effect on performance in the educational program. 3.0 Trainee The trainee is responsible for: 3.1 Participating fully in all aspects of their training. 3.2 Providing accurate documentation of actual hours worked as required by institutional and program policy in a timely fashion. Page 6 of 9
3.3 Reporting problems with duty hour schedules or actual time worked as soon as possible to the program director or institutional personnel. Page 7 of 9
ATTACHMENTS / LINKS RELATED POLICIES JOINT COMMISSION STANDARDS / NATIONAL PATIENT SAFETY GOALS OTHER RELATED ACCREDITATION / REGULATORY STANDARDS REFERENCES Page 8 of 9
POLICY APPROVAL Approved With Revisions Date: 07/21/2016 Approved Without Revisions Date: Implementation Date: 07/21/2016 Version: 15.0 RESPONSIBLE DEPARTMENT(S) Academic & Visa Admin: Trainee & Alumni Affairs Page 9 of 9