ACGME Resident Duty Hours Communication

COMMON PROGRAM REQUIREMENTS
For insertion into all specialty/subspecialty program requirements

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Institutional Support
1. Sponsoring Institution
  One sponsoring institution must assume the ultimate responsibility for the program as described in the Institutional Requirements, and this responsibility extends to resident assignments at all participating institutions.
2. Participating Institutions
  1. Assignments to participating institutions must be based on a clear educational rationale, must have clearly stated learning objectives and activities, and should provide resources not otherwise available to the program.
  2. Assignments at participating institutions must be of sufficient length to ensure a quality educational experience and should provide sufficient opportunity for continuity of care. Although the number of participating institutions may vary with the various specialties' needs, all participating institutions must demonstrate the ability to promote the program goals and educational and peer activities. Exceptions must be justified and prior-approved by the Residency Review Committee (RRC).
  3. Program letters of agreement must be developed for each participating institution that provides an educational experience for a resident that is one month in duration or longer. In instances where two or more participating institutions in the program function as a single unit under the authority of the program director, letters are not necessary. The agreements should
    1. identify the faculty who will assume educational and supervisory responsibility for residents and specify the faculty responsibilities for teaching, supervision, and formal evaluation of resident performance per Sections IV.D. and V.A. of the Program Requirements;
    2. outline the educational goals and objectives to be attained by the resident during the assignment;
    3. specify the period of resident assignment;
    4. establish the policies and procedures that will govern resident education during the assignment.
Resident Appointment
1. Eligibility Criteria
  The program director must comply with the criteria for resident eligibility as specified in the Institutional Requirements.
2. Number of Residents
  An RRC may approve the number of residents based upon established written criteria that include the adequacy of resources for resident education such as quality and volume of patients and related clinical material available for education, faculty-resident ratio, institutional funding, and the quality of faculty teaching.
3. Resident Transfer
  To determine the appropriate level of education for a resident who is transferring from another residency program, the program director must receive written verification of the previous educational experiences and a statement regarding the performance evaluation of the transferring resident, including an assessment of competence in the six areas described in section IV.B., prior to acceptance into the program. A program director is required to provide verification of residency education for any residents who may leave the program prior to completion of their education.
4. Appointment of Fellows and Other Students
  The appointment of fellows and other specialty residents or students must not dilute or detract from the educational opportunities of the regularly appointed specialty residents.
Faculty

The program director and faculty are responsible for the general administration of the program and for the establishment and maintenance of a stable educational environment. Adequate lengths of appointment for the program director and faculty are essential to maintaining such an environment. The length of appointment for the program director should provide for continuity of leadership.
1. Qualifications of the Program Director
  1. There must be a single program director responsible for the program. The person designated with this authority is accountable for the operation of the program and should be a member of the staff of the sponsoring or integrated institution.
  2. The program director must
    1. possess requisite specialty expertise as well as documented educational and administrative abilities and experience in his or her field.
    2. be certified in the specialty by the applicable American Board of Medical Specialties (ABMS) Board or possess qualifications judged to be acceptable by the RRC.
    3. be appointed in good standing and based at the primary teaching site.
2. Responsibilities of the Program Director
  1. Overseeing and organizing the activities of the educational program in all institutions that participate in the program. This includes selecting and supervising the faculty and other program personnel at each participating institution, appointing a local site director, and monitoring appropriate resident supervision at all participating institutions.
  2. Preparing an accurate statistical and narrative description of the program as requested by the RRC as well as updating annually the program and resident records through the ACGME Accreditation Data System (ADS).
  3. Promptly notifying the executive director of the RRC using the ADS of a change in program director or department chair.
  4. Grievance procedures and due process: The program director must ensure the implementation of fair policies and procedures, as established by the sponsoring institution, to address resident grievances and due process in compliance with the Institutional Requirements.
  5. Monitoring of resident well-being: The program director is responsible for monitoring resident stress, including mental or emotional conditions inhibiting performance or learning, and drug- or alcohol-related dysfunction. Both the program director and faculty should be sensitive to the need for timely provision of confidential counseling and psychological support services to residents. Situations that demand excessive service or that consistently produce undesirable stress on residents must be evaluated and modified.
  6. Obtaining prior approval of the RRC for changes in the program that may significantly alter the educational experience of the residents, for example:
    1. The addition or deletion of major participating institution(s) as specified in section I.B.2 of this document.
    2. Change in the approved resident complement for those specialties that approve resident complement.
    3. Change in the format of the educational program.
    On review of a proposal for a major change in a program, the RRC may determine that a site visit is necessary.
3. Faculty Qualifications
  1. The physician faculty must
    1. possess requisite specialty expertise as well as documented educational and administrative abilities and experience in their field.
    2. be certified in the specialty by the applicable American Board of Medical Specialties (ABMS) Board or possess qualifications judged by the RRC to be acceptable.
    3. be appointed in good standing to the staff of an institution participating in the program.
  2. Nonphysician faculty must be appropriately qualified in their field and possess appropriate institutional appointments.
4. Faculty Responsibilities
  1. At each institution participating in the program, there must be a sufficient number of faculty with documented qualifications to instruct and supervise adequately all residents in the program.
  2. Faculty members must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities. The faculty must evaluate in a timely manner the residents whom they supervise.
  3. The faculty must demonstrate a strong interest in the education of residents, demonstrate competence in both clinical care and teaching abilities, support the goals and objectives of the educational program, and demonstrate commitment to their own continuing medical education by participating in scholarly activities as described in Section IV.C.1.
5. Other Program Personnel
  The program must be provided with the additional professional, technical, and clerical personnel needed to support the administration and educational conduct of the program.
The Educational Program

The program design and sequencing of educational experiences will be approved by the R.R.C. as part of the accreditation process.
1. Role of Program Director and Faculty
  1. The program director, with assistance of the faculty, is responsible for developing and implementing the academic and clinical program of resident education by
    1. preparing and implementing a written statement outlining the educational goals of the program with respect to the knowledge, skills, and other attributes of residents for each major assignment and each level of the program. The statement must be distributed to residents and faculty and reviewed with residents prior to the assignment.
    2. preparing and implementing a comprehensive, well-organized, and effective curriculum, both academic and clinical, which includes the presentation of core specialty knowledge supplemented by the addition of current information.
    3. providing residents with direct experience in progressive responsibility for patient management.
2. ACGME Competencies [Note: The ACGME does not require RRCs to add section IV.B to the program requirements for subspecialty programs. If an RRC elects to add the general competencies to its subspecialty program requirements, program directors will be notified and given an opportunity to provide written comments regarding the proposed change.] The residency program must require that its residents obtain competence in the six areas listed below to the level expected of a new practitioner. Programs must define the specific knowledge, skills, behaviors, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate the following:
  1. Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
  2. Medical knowledge about established and evolving biomedical, clinical, and cognate (eg, epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
  3. Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.
  4. Interpersonal and communication skills that result in effective information exchange and collaboration with patients, their families, and other health professionals.
  5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
  6. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.
3. Scholarly Activities
  1. The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the faculty, and an active research component must be included within each program. Both faculty and residents must participate actively in scholarly activity. Scholarship is defined as one of the following:
    1. The scholarship of discovery, as evidenced by peer-reviewed funding or publication of original research in peer-reviewed journals.
    2. The scholarship of dissemination, as evidenced by review articles or chapters in textbooks.
    3. The scholarship of application, as evidenced by the publication or presentation at local, regional, or national professional and scientific society meetings, for example, case reports or clinical series.
    4. Active participation of the teaching staff in clinical discussions, rounds, journal club, and research conferences in a manner that promotes a spirit of inquiry and scholarship; offering of guidance and technical support, e.g., research design, statistical analysis, for residents involved in research; and provision of support for resident participation as appropriate in scholarly activities.
  2. Adequate resources for scholarly activities for faculty and residents must be available, eg, sufficient laboratory space, equipment, computer services for data analysis, and statistical consultation services.
4. Resident Duty Hours and the Working Environment
  Providing residents with a sound academic and clinical education must be 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. Didactic and clinical education must have priority in the allotment of residents' time and energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.
  1. Supervision of Residents
    1. All patient care must be supervised by qualified faculty. The program director must ensure, direct, and document adequate supervision of residents at all times. Residents must be provided with rapid, reliable systems for communicating with supervising faculty.
    2. Faculty schedules must be structured to provide residents with continuous supervision and consultation.
    3. Faculty and residents must be educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract the potential negative effects.
  2. Duty Hours
    1. Duty hours are defined as all clinical and academic activities related to the residency program, ie, patient care (both inpatient and outpatient), 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. Duty hours do not include reading and preparation time spent away from the duty site.
    2. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
    3. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
    4. 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.
  3. On-Call Activities
    The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution.
    1. In-house call must occur no more frequently than every third night, averaged over a four-week period.
    2. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents 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 Specialty and Subspecialty Program Requirements.
    3. No new patients, as defined in Specialty and Subspecialty Program Requirements, may be accepted after 24 hours of continuous duty.
    4. At-home call (pager call) is defined as call taken from outside the assigned institution.
      1. 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 resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.
      2. When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit.
      3. The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.
  4. Moonlighting
    1. Because residency education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program.
    2. The program director must comply with the sponsoring institution's written policies and procedures regarding moonlighting, in compliance with the Institutional Requirements III. D.1.k.
    3. Moonlighting that occurs within the residency program and/or the sponsoring institution or the non-hospital sponsor's primary clinical site(s), ie, internal moonlighting, must be counted toward the 80-hour weekly limit on duty hours.
  5. Oversight
    1. Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment. These policies must be distributed to the residents and the faculty. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service.
    2. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.
  6. Duty Hours Exception
    An RRC may grant exceptions for up to 10 % of the 80-hour limit, to individual programs based on a sound educational rationale. However, prior permission of the institution's GMEC is required.
Evaluation
1. Resident Evaluation
  1. The residency program must demonstrate that it has an effective plan for assessing resident performance throughout the program and for utilizing the results to improve resident performance. This plan should include:
    1. the use of methods that produce an accurate assessment of residents' competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.
    2. mechanisms for providing regular and timely performance feedback to residents that includes at least
      1. written semiannual evaluation that is communicated to each resident in a timely manner and
      2. the maintenance of a record of evaluation for each resident that is accessible to the resident.
    3. a process involving use of assessment results to achieve progressive improvements in residents' competence and performance. Appropriate sources of evaluation include faculty, patients, peers, self, and other professional staff.
  2. The program director must provide a final evaluation for each resident who completes the program. The evaluation must include a review of the resident's performance during the final period of education and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently. The final evaluation must be part of the resident's permanent record maintained by the institution.
2. Faculty Evaluation
  The performance of the faculty must be evaluated by the program no less frequently than at the midpoint of the accreditation cycle and again prior to the next site visit. The evaluations should include a review of their teaching abilities, commitment to the educational program, clinical knowledge, and scholarly activities. Annual written confidential evaluations by residents must be included in this process.
3. Program Evaluation
  The educational effectiveness of a program must be evaluated at least annually in a systematic manner.
  1. Representative program personnel, ie, at least the program director, representative faculty, and at least one resident, must be organized to review program goals and objectives and the effectiveness of the program in achieving them. The group must have regular documented meetings at least annually for this purpose. In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution (see Institutional Requirements I.B.3.d), and the residents' confidential written evaluations. If deficiencies are found, the group should prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes.
  2. Outcome assessment
    1. The program should use resident performance and outcome assessment in its evaluation of the educational effectiveness of the residency program.
    2. The program should have in place a process for using resident and performance assessment results together with other program evaluation results to improve the residency program.
  3. Performance of program graduates on the certification examination should be used as one measure of evaluating program effectiveness.
Experimentation and Innovation
1. Since responsible innovation and experimentation are essential to improving professional education, experimental projects supported by sound educational principles are encouraged.
2. Requests for experimentation or innovative projects that may deviate from the program requirements must be RRC prior-approved and must include the educational rationale and a method for evaluating the project.
3. The sponsoring institution and program are jointly responsible for the quality of education offered to residents for the duration of such a project.

ACGME: February 2002
Duty Hour Requirements Approved February 2003
Effective: July 2003

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COMMON PROGRAM REQUIREMENTS For insertion into all specialty/subspecialty program requirements

COMMON PROGRAM REQUIREMENTS
For insertion into all specialty/subspecialty program requirements