SECTION 6: DUTY HOURS AND MOONLIGHTING POLICIES
6.01 DUTY HOURS POLICY
It is the policy of Graduate Medical Education to follow guidelines established by the ACGME regarding duty hours for residents in accredited training programs. Specific details can be found at the ACGME website, acgme.org.
- Residents must not work more than 80 hours per week averaged over a month,
- Residents must receive at least 10 hours between shifts,
- Residents must not work more than 24 continuous with 6 additional hours for patient transfer or brief didactic sessions,
- Residents must not take in-house call more frequently than once every third night, and
- Residents must receive at least one day in seven away from clinical duties.
All programs must have policies for duty hours that at minimum meet the ACGME’s institutional and program requirements. Programs must monitor in-house and from-home duty hours on an ongoing basis in a way that provides accurate data. The Duty Hour subcommittee will establish reporting requirements. Each monitoring period must be 4 weeks in length. With GMEC oversight, the DIO and the Chair of the GMEC Duty Hour Sub-committee will review program data resulting from internal reviews, annual administrative processing sessions, random audits and other times as determined by the DIO, the GMEC or by the Duty Hour Sub-committee of the GMEC. If a program has received approval from the ACGME to extend the 80-hour rule, if the program received a duty hour citation or if an internal review reveals a duty hour issue, then these training programs must send reports to the sub-committee at a minimum of every other month.
Program Directors must monitor call-from-home duty hours in terms of frequency and characteristics to assure that residents and fellows are following basic guidelines established by the ACGME.
Program Directors must provide information to residents and fellows regarding effects of loss of sleep and chronic fatigue.
REPORTING STRUCTURE FOR OFF-SERVICE ROTATIONS
It is the intention of this policy to establish a process that will address duty hour compliance in a rapid and timely manner. Problems regarding compliance with duty hour guidelines should be reported to the Chief Resident of the accepting training program. If that Chief Resident does not respond to the report of noncompliance, then the resident should report to the Program Director of the sending program. The Program Directors of the two programs must address the issues that led to the violation of the guidelines. The resident may notify the GME Office at any time. The Associate Dean for GME will report to the Chairs of the two training programs and has the option of reporting to the Dean if the issues are not settled on an immediate basis.
6.02 DUTY HOUR EXTENSION
On occasion, individual programs could determine a need to extend the 80-hour work rule to a maximum of 10% above the current limit or a total of 88 hours per week. No other extension of the ACGME guidelines is permitted unless specifically stated by the ACGME. Not all RRC’s accept applications to extend the 80-hour guideline.
If the request to extend work hours has been approved by the GMEC, then Program Directors must petition the RRC for permission to extend hours. The letter from the GMEC must be used when communicating to the RRC.
Program Directors must use the following guidelines to petition the GMEC.
- Program Directors requesting an extension of duty hours must do so in writing to the Associate Dean for GME.
- Blanket exceptions for the entire educational program should be considered the exception, not the rule.
- The letter must include the following information.
- A description of the resident’s work week to delineate specific problem areas,
- A clear explanation of why the program cannot maintain the 80-hour limit,
- A clarification of the RRC requirements the program will not meet if residents work 80 or fewer hours,
- Planned monitoring procedures to assure that residents will not work greater than 88 hours per week,
- Information describing how the program will monitor, evaluate and ensure patient safety with extended resident work hours,
- A sound educational rationale that should relate to the program’s stated goals and objectives for the particular assignments, rotations and levels of training for which the increase is requested,
- The program’s moonlighting policies and how the program will assure that it is accounting for these hours,
- Call schedules for the rotation in question and
- Evidence of faculty development activities regarding the effects of residents fatigue and sleep deprivation.
- The GMEC Sub-committee on Duty Hours will serve as the ad hoc committee to review requests for extensions of duty hours. The Associate Dean will review the membership of the GMEC Sub-committee to assure that conflicts of interest do not enter the decision process.
- The written findings and recommendations of the Sub-committee will be presented at the next regularly scheduled meeting of the GMEC.
- Members of the GMEC, based on the letter from the Program Director and the findings and recommendations of the Sub-committee, will develop its report and send this report to the Program Director.
- The decision of the GMEC is final.
- Program Directors will not implement the extension of duty hours until approved by the ACGME.
- Program Directors must monitor resident work hours on a more intense basis if the ACGME has granted an extension.
6.03 MOONLIGHTING POLICY
“Moonlighting” refers to a service performed by a resident in the capacity of an independent physician, completely outside the scope of his/her residency-training program. “External moonlighting” refers to moonlighting at a facility that is not part of the resident’s training program. “Internal moonlighting” refers to moonlighting at an Emory facility or any other facility where the resident is receiving training as part of the residency-training program.
Residents are not required to engage in moonlighting.
Residents are prohibited from external or internal moonlighting UNLESS they have the written approval of the Chair of the Department or his/her designee. The requirements necessary for such approval are set forth below under “External Moonlighting” and “Internal Moonlighting.”
Residents do not have insurance coverage through Emory’s Residency Training Program for any moonlighting services, whether external or internal.
In addition to the requirements below, the Chair or his/her designee’s decision to approve or deny a resident’s request to moonlight will depend on a number of factors including, but not limited to, interference with the resident’s responsibilities in the training program and the individual circumstances of the resident.
6.04 External Moonlighting Requirements:
- The Resident must submit a written request for approval to externally moonlight by completing the “Request to do External Moonlighting” form obtained either from the Program Director, Program Coordinator or from Appendix D in this House Staff Manual.
- In order to be considered for external moonlighting, the resident must meet the following requirements:
- Residents must agree to obtain a signed contract with the external facility and provide a copy of the signed contract to the Program Director. The contract must state that the facility will provide professional liability insurance coverage for the resident’s moonlighting services and that the resident has received privileges. If the facility does not provide insurance coverage, residents must obtain their own professional liability insurance and provide proof of such insurance to the Program Director before moonlighting begins.
- Residents must be fully licensed to practice medicine in the state where the moonlighting will occur. A residency-training permit is not a license to practice medicine outside the scope of residency training.
- Residents on J-1 Visas are prohibited from moonlighting.
- Residents must not wear identifiers as trainees in Emory University School of Medicine residency-training programs.
- External moonlighting does not count toward the 80-hour limit set by the ACGME. The Chair of the Department and the Program Director are expected and required to assess the resident’s progress in the program and ask the resident to stop moonlighting if performance does not reach an expected level. The resident must be aware of these expected levels of academic and clinical performance before beginning the moonlighting experience.
6.05 Internal Moonlighting Requirements:
- The Resident must submit a written request for approval to internally moonlight by completing the “Request to do Internal Moonlighting” form obtained either from the Program Director, Program Coordinator or from Appendix D in this House Staff Manual.
- In order to be considered for internal moonlighting, the resident must meet the following requirements:
- Residents must agree to obtain a signed contract with the facility and provide a copy of the signed contract to the Program Director. The contract must state that the facility will provide professional liability insurance coverage for the moonlighting services and that the resident has received privileges. If the facility does not provide insurance coverage, residents must obtain their own professional liability insurance and provide proof of such insurance to the Program Director before moonlighting begins.
- Internal moonlighting services may occur only in an OUTPATIENT SETTING or in the EMERGENCY DEPARTMENT. Federal Medicare regulations are very clear on this point. (42 CFR 415.208)
- Residents must be fully licensed to practice medicine in the State of Georgia. A residency-training permit is not a license to practice medicine outside the scope of residency training.
- Residents on J-1 Visas are prohibited from moonlighting.
- Resident must not wear identifiers as trainees in Emory University School of Medicine residency-training programs
- Residents must assure the Program Director in writing that the total hours in residency training and the moonlighting commitment DO NOT EXCEED the limits set by the ACGME. Fabrication of the duty hour information could result in termination from the training program.
(GME) Office of Graduate Medical Education