Work Hour Policy

I. Purpose of policy

This policy delineates the clinical experience and education work hour limitations for Residents training in Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs at Dartmouth-Hitchcock (D-H).

II. Policy scope

This policy applies to all Residents, Program Directors, Program Coordinators and Faculty Members involved in ACGME-accredited training programs and to Graduate Medical Education (GME) Staff at D-H.

III. Definitions

Resident: Any physician in an ACGME-accredited graduate medical education program including residents and fellows.

Clinical Experience and Education Work Hours: All clinical and academic activities related to the program.

IV. Policy statement

  1. Clinical Experience and Education Work Hours:

    All residency and fellowship programs will adhere to the following work hour requirements mandated by the ACGME, specialty-specific Review Committee (RC), and D-H as defined below.

    1. Clinical and Educational Work Activities:

      Residents must report the following work activities:

      • Patient care:
        • Inpatient and outpatient care occurring at the hospital or while at home
        • Administrative duties related to patient care occurring at the hospital or while at home
        • Electronic Medical Record (EMR) note writing, preparation of discharge summaries, phone calls related to patient care, while at home or at the hospital
        • The provision for transfer of patient care / sign-outs
        • Time spent in-house during call activities
      • Education/Academic:
        • Scheduled academic activities such as conferences or unique educational events
        • Research
        • Time spent at regional/national conferences/meetings when attendance at the meeting is required by the program, or when the Resident is acting as a representative of the program (i.e. presenting a paper or poster). Only actual meeting time counts towards work hours.
        • Hours spent on activities that are required by the accreditation standards, such as membership on a hospital committee, or that are accepted practice in residency programs, such as Residents’ participation in interviewing residency candidates.
      • The following activities are excluded from work hour reporting:
        • Academic preparation time, such as time spent preparing for presentations or journal club, board review, or other reading and study time.
        • Travel and non-conference time when at a regional/national conference/meeting.
    2. Maximum Hours of Clinical and Educational Work per Week:
      • Clinical and educational work must be limited to no more than 80 hours per week, averaged over 28 days or the length of the rotation block, whichever is shorter.
      • Rotations shorter than 28 days must be fully compliant with the 80-hour and one-day-off-in-seven rules. Averaging shorter blocks of high intensity and low intensity rotations is not allowed.
      • When vacation is taken during a block, the remainder of the block must be compliant with all clinical and educational work hour rules.
    3. Mandatory Time Free of Clinical Work and Education:
      • 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.
      • Resident should have eight hours off between scheduled clinical work and education periods.
        • Residents may choose to stay to care for 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.
      • Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.
      • Residents must be scheduled for a minimum of one day in seven free of clinical work and required education (when averaged over four weeks).
        • At-home call cannot be assigned on these free days.
        • It is not permissible to have the day off regularly or frequently scheduled on a Resident’s post-call day but in smaller programs it may occasionally be necessary to have the day off fall on the post-call day.
    4. Maximum Clinical Work and Education Period Length:
      • 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. Clinical and Educational Work Hour Exceptions:
      • In rare circumstances, after handing off other responsibilities, a Resident, on the Resident’s 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.
    6. Moonlighting: Please see the Moonlighting Policy (PDF).
    7. In-House Night Float: Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.
    8. In-House Call: Residents must not be scheduled for in-house call more frequently than every third night (when averaged over a four-week period).
    9. At-Home Call: At-home call (pager call) is call taken from outside the assigned institution. While scheduled for at-home call a Resident may return to the hospital to provide direct patient care for new or established patients. Home call is only appropriate if the service intensity and frequency of being called in is low.
      • Frequency:The frequency of at-home call is not subject to the every third night limitation.
        • 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 one-day-in-seven completely free from all educational and clinical responsibilities, averaged over a four-week period.
      • Reporting of Hours:Residents must report time spent on patient care activities while at home, including pages, phone calls and EMR documentation as well as time spent in the hospital providing direct care for new or established patients. These hours count toward the 80-hour work limit.
      • The Program Director and the faculty must monitor the demands of at-home call in the program and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.
  2. Program-Level Policy
    • The D-H Graduate Medical Education Committee (GMEC) will not accept for review, nor endorse any applications from individual GME training programs seeking exceptions to ACGME work hour rules and regulations.
    • Each D-H training program, regardless of ACGME-accreditation status, must have written policies and procedures consistent with the Institutional and Program Requirements for Resident clinical experience and work hours.
      • Program specific Work Hour policies must include procedures to ensure coverage of patient care in the event that a Resident is be unable to attend work due to fatigue, illness, or family emergency.
      • Program specific Work Hour policies must be uploaded to the Residency Management System, MedHub, for ready access by faculty and Residents.

V. References

Common Program Requirements. (2017). Retrieved from ACGME.org:

D-H Policy ID: 11303