Clinical and Educational Work Hours

Scope

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Policy Statement

Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. In coordination with the institution, the program director must administer and maintain an educational environment conducive to educating the residents in each of the ACGME competency areas. The program director must monitor resident clinical and educational work hours, according to sponsoring institutional policies, with a frequency sufficient to ensure compliance with institutional requirements. The program must design an effective program structure that is configured to provide residents with educational opportunities, as well as reasonable opportunities for rest and personal well-being. 

Clinical and Educational Work Hours 

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. Work assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. The structuring of work hours and on-call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident.  The clinical and educational work hours policy applies to all participating hospitals where training of residents occurs.   

1. Work hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent on in-house call, and other scheduled activities, such as conferences. Work hours do not include reading and preparation time spent away from the work site.
2. When research is a formal part of the residency/fellowship and occurs during the accredited years of the program, research hours or any combination of research and patient care activities must comply with the weekly limit on hours and other pertinent clinical and educational work hour requirements. 
   When programs offer an additional research year that is not part of the accredited years, or when residents/fellows conduct research on their own time, making these hours identical to other personal pursuits, these hours do not count toward the limit on clinical and educational work hours. The combined hours spent on self-directed research and program-required activities should meet the test for a reasonably rested and alert resident/fellow when the resident/fellow participates in patient care.
   Some programs have added clinical activities to “pure” research rotations, such as having research residents/fellows cover “night float.” This combination of research and clinical assignments could result in hours that exceed the weekly limit and could also seriously undermine the goals of the research rotation. Review Committees have traditionally been concerned that required research not be diluted by combining it with significant patient care assignments.
3. Work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting.
4. Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.  Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident education.  Additional patient care responsibilities must not be assigned to a resident during this time.
5. Residents must be scheduled for a minimum of 1 day in 7 free from clinical work and required education averaged over a 4-week period, inclusive of call (at-home call cannot be scheduled for this day).  One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.  At-home call cannot be assigned on these free days.
   1. It is desirable that days off be distributed throughout the month, but some residents may prefer to group their days off to have a “golden weekend,” meaning a consecutive Saturday and Sunday free from work. The requirement for one free day in seven should not be interpreted as precluding a golden weekend. Where feasible, schedules may be designed to provide residents with a weekend, or two consecutive days, free of work.  Programs are encouraged to distribute days off in a fashion that optimizes resident well-being, and educational and personal goals.
6. Residents should have eight hours off between scheduled clinical work and education periods.  There may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80- hour and the one-day-off-in-seven requirements.
7. Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.

Clinical and Educational Work Hour Exceptions 

In rare circumstances, after handing off all other responsibilities, a resident, on their own initiative, may elect to remain or return to the clinical site in the following circumstances:

• to continue to provide care to a single severely ill or unstable patient
• to provide humanistic attention to the needs of a patient or family, or
• to attend unique educational events. 

These additional hours of care or education will be counted toward the 80-hour weekly limit.  

In-House Night Float and 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 work hours beyond the normal work day when residents are required to be immediately available in the assigned institution.  

Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.  Residents must be scheduled for in-house call no more frequently than every third night (when averaged over a four-week period). 

At-Home Call                                         

Time spent on patient care activities by residents on at-home call must count toward the 80-hour maximum weekly limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one day in seven free of clinical work and education, when averaged over four weeks.  At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident. Work done from home includes time spent updating medical records or answering work-related phone calls, and not the entirety of the home call period.  Studying and research do not count as work done at home.  
Residents are permitted to return to the hospital while on at-home call to provide direct care for new or established patients. These hours of inpatient patient care must be included in the 80-hour maximum weekly limit. 

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Reason for Policy

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Definitions

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Implementation

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Oversight

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History

1. Policy gme-adm-0006 approved by GMEC on 13 February 2013. 
2. Policy reviewed, updated, and approved by GMEC, and published on 24 May 2017. 
3. Policy updated for formatting 27 February 2018. 
4. Policy updated for formatting 27 June 2018. 
5. Policy revised 31 July 2019. 
6. Policy approved by the GMEC 04 December 2019. 
7. Policy updated 26 February 2024.
8. Policy approved by GMEC 20 March 2024. 

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