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Resident and Fellow Policy Manual

Appendix 1 - Institutional Oversight/Monitoring of Resident/Fellow Duty Hours:

I. Educational Process

a. All new trainees are instructed regarding the institution's duty hour policies at general and program-specific orientation sessions.

b. Full descriptions of institutional policies regarding duty hours, monitoring activities and moonlighting are available to all trainees and faculty via the GME website (see Resident/Fellow Manual for Medical and Dental Programs).

c. Program directors must distribute departmental policies regarding duty hours to residents and faculty.  The program directors will communicate with program faculty/trainees regarding changes in duty hour policies or changes in trainee/faculty work hours to accommodate duty hour requirements.

II. Monitoring Process

A. Internal Measures

1. Twice yearly, the GME office will conduct an internal audit of all trainees in ACGME/ABMS sponsored programs within the university.

a. Surveys are distributed via program coordinators to all trainees.  The survey includes instructions for completing the survey and states that the survey is mandatory and anonymous.

b. Trainees are instructed to record their activities over a consecutive 2-week period of time (out of 6 possible weeks) while on one rotation, exclusive of vacation.

c. Surveys are returned to the GME office for evaluation.

d. Returned surveys are sent to a data service provider for data entry and download of the file to the Office of Clinical Practice Evaluation.  They run two reports:

i) One report has the following headings and provides data for each of the rotations in a training program:

  • Number of respondents
  • Mean hours per week for all residents
  • Hours per week for maximum resident
  • Percent of weeks over 85 hours on
  • Percent of resident/fellows who worked over 170 hours in a 2-week period
  • Percent of residents/fellows with 28 hours on
  • Percent of residents without two 24-hour periods off in 2 weeks

ii) Summary of threshold values by program:  This report summarizes the totals in each of the categories listed above for each program.  It is used by administration to evaluate the program's overall compliance.  The report also shows the totals for all programs, which helps to monitor institutional compliance.

e. Data from the reports are evaluated and distributed as described in reporting process.

2. As part of each program's Internal Review process, work hours are evaluated by the survey team.

a. The program is required to provide a copy of its work hours policy and general guidelines regarding trainee work hours, such as typical start and end times for daily work, method and amount of in-house and pager call, etc.

b. Recent data from internal audits and external (NYS) audits regarding the program are provided by the GME office to the review committee.

c. Trainees in core programs with more than 5 individuals are asked to fill out a web-based survey with questions pertaining to work hours prior to the internal review.

d. Faculty and trainees are questioned during the review regarding the program's compliance with work hour regulations and promotion of safe patient care practices.

B. External Measures

  1. NYSDOH has informed all training programs within NYS that unannounced visits will occur on at least an annual basis for all training institutions.  The University of Rochester and its trainees will participate fully in this NYS monitoring process.
  2. The ACGME will evaluate a program's compliance with duty hour regulations as part of regularly conducted site visits.  This may include surveying trainees prior to a site visit and discussing duty hour compliance with trainees and faculty during the visit.  The University of Rochester and its trainees will participate fully in this accreditation-based monitoring process.

 

III. Reporting Process

a. Data from internal GME office surveys are discussed at meetings of the GME Committee (GMEC).  Aggregate results are distributed to program directors, department chairs, program coordinators, university administrators and the Office of Counsel

b. Programs out of compliance are asked to evaluate their data.  If compliance cannot be obtained easily by alteration of trainee schedules, the program director and department chair are asked to meet with the Associate Dean for Graduate Medical Education (ADGME), Chief Operating Officer (COO) of the hospital, and a representative from the Office of Counsel to develop a plan to facilitate compliance.

c. Concerns regarding work hours discussed at program internal reviews are documented in the internal review report and discussed by the GMEC.

d. Concerns regarding work hours found as part of ACGME external reviews are reviewed when accreditation status letters are discussed at GMEC.

e. Findings from NYS work hour audits are shared with GMEC, program directors, chairs, trainees, the Office of Counsel, and hospital/university administrators.  If the institution is found to be out of compliance by NYS, the ADGME, COO, and Office of Counsel will draft a correction/monitoring plan that meets state requirements.

f. At least two times a year the ADGME presents a report regarding work hours compliance to the organized medical staff of the institution (Clinical Chiefs and Chairs and the Medical Center Executive Committee) as well as to the Joint Committee on the Quality of Care which consists of the University of Rochester Medical Center Board Subcommittee on the Quality of Care and the Strong Memorial Hospital Quality Assurance Committee.  This report includes information from all internal and external monitoring events.  Each of these committees may assist the ADGME in assuring institutional compliance with duty hour requirements.