Clinical and Educational Work Hours Policy

Clinical experience and education are defined as all clinical and academic activities related to the residency program; i.e., 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. Clinical work and education hours do not include reading and preparation time spent away from the clinical and educational site.

The following institutional policy applies to all programs and residents/fellows.

Purpose

In compliance with the ACGME Institutional and Common Program Requirements, it is the goal of the Hospital as the Sponsoring Institution to provide residents/fellows with a sound academic and clinical education.

Scope

UAB has developed the following Clinical Experience and Education Policies applicable to every resident/fellow in all GME training programs.

Definitions Based on ACGME Requirements

At-Home Call: Same as pager call or call taken from outside the assigned site. Time spent in the hospital, exclusive of travel time, counts against the 80-hour per week limit but does not restart the clock for time off between scheduled in-house duty periods. At-Home Calls may not be scheduled on the resident’s one free day per week (averaged over four weeks). PGY-1 residents are not allowed to take at-home call because appropriate supervision (either direct supervision or indirect supervision with direct supervision immediately available) is not possible when a resident is on at-home call.

Continuous time on duty: The period that a resident is in the hospital (or another clinical care setting) continuously, counting the resident’s regular scheduled day, time on call, and the hours a resident remains on duty after the end of the on-call period to transfer the care of patients and for didactic activities.

Fatigue management: Recognition by either a resident or supervisor of a level of resident fatigue that may adversely affect patient safety and enact a solution to mitigate the fatigue.

In-House Call: Hours beyond the typical workday when residents are required to be immediately available in the assigned institution.

Moonlighting: Voluntary, compensated, medically related work (not related to training requirements) performed.

Night Float: Rotation or educational experience designed to either eliminate in-house call or to assist other residents/fellows during the night. Residents/fellows assigned to night float are assigned on-site duty during evening/night shifts and are responsible for admitting or cross-covering patients until morning and do not have daytime assignments. Rotation must have an educational focus.

One Day Off: One (1) continuous 24-hour period free from all administrative, clinical and educational activities.

Scheduled clinical work and education period length: Assigned clinical and educational work within the institution encompassing hours, which may be within the normal workday, beyond the normal workday, or a combination of both.

Strategic napping: Short sleep periods, taken as a component of fatigue management, which can mitigate the adverse effects of sleep loss.

Work Hours: 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 away from the clinical or educational site.
Hours spent on activities required by the accreditation standards, such as membership on a hospital committee, or that are accepted practice in residency programs, such as residents/fellows’ participation in interviewing residency/fellowship candidates, must be included in the count of work hours. It is not acceptable to expect residents/fellows to participate in these activities during their hours; nor should residents/fellows be prohibited from participating in them.

Policy

Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents/fellows to fulfill service obligations. Didactic and clinical education must prioritize the allotment of residents/fellows' time and energy. Work hours assignments must recognize that faculty and residents/fellows collectively have responsibility for the safety and welfare of patients.

1. The program director must
   • be familiar with the ACGME and Review Committee policies as well as institutional policies and procedures governing clinical and educational work hours and the procedures for requesting exceptions.
   • implement policies and procedures for clinical and educational work hours consistent with the institutional and program requirements for resident/fellow clinical and educational work hours and the working environment, including moonlighting.
   • distribute these policies and procedures to the residents/fellows and faculty.
   • monitor honest and accurate reporting of resident/fellow clinical and educational work hours, according to sponsoring institutional policies, with a frequency sufficient to ensure compliance with institutional and ACGME requirements.
   • adjust schedules as necessary to mitigate excessive service demands and/or fatigue.
   • if applicable, monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue.
   • educate residents/fellows and faculty concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients.
   • encourage residents/fellows to use fatigue mitigation strategies in the context of patient care responsibilities.
   • comply with any additional requirements as outlined in the ACGME specialty-specific program requirements.
2. The residents/fellows [and supervising faculty] must demonstrate an understanding and acceptance of their role in the following:
   • assurance of the safety and welfare of patients entrusted to their care.
   • knowledge of and compliance with all ACGME clinical and educational work hours requirements.
   • management of their time before, during, and after clinical assignments to ensure fitness to perform their assigned responsibilities.
   • ensure coverage for clinical activity in the hospital if you are unable to fulfill your responsibility; and
   • honest and accurate reporting of hours according to this policy.
   • Clinical work done from home includes: using the electronic health record and taking calls from home. It does not include reading done in preparation for the following day’s cases, studying, and research done from home.

Clinical and Educational Work Hours

1. Clinical and educational 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.
2. Residents/Fellows 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.
3. Residents/Fellows should have eight hours off between scheduled clinical work and education periods. There may be circumstances when residents/fellows 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.
4. Residents/Fellows must have at least 14 hours free of clinical work and education after 24 hours of in-house call.
5. Clinical and educational work periods for residents/fellows 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 resident/fellow education. Additional patient care responsibilities must not be assigned to a resident/fellow during this time.

Clinical and Educational Work Hours Exceptions

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

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

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

At-Home Call

Time spent on patient care activities by residents/fellows on at-home calls must count toward the 80-hour maximum weekly limit. The frequency of at-home calls is not subject to 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 calls must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident/fellow.

Moonlighting

1. PGY-1 residents/fellows may not moonlight.
2. Moonlighting policies should be established within each program but must comply with ACGME requirements.
3. Moonlighting activity hours will be counted toward the work hours and logged appropriately.
4. The program director ensures moonlighting activities do not impact hospital coverage.
5. Time spent by residents/fellows on moonlighting must be counted towards the 80 hours Maximum Weekly Limit. All moonlighting and work hours must be recorded in the resident management system (MedHub). Moonlighting residents/fellows will be required to log all hours for the whole month, regardless of whether the program is monitoring clinical and educational work hours that month.

In-House Night Float: Night float must occur within the context of the 80-hour per week and one-day-off-in-seven requirements. Programs should be familiar with specialty requirements of the maximum number of consecutive weeks of night float and maximum number of months of night float per year.

Maximum In-House On-Call Frequency: Residents/Fellows must be scheduled for in-house call no more frequently than every third night (when averaged over a four-week period).

Oversight and Monitoring of Clinical Experience, Education, and the Work Environment

Programs, in partnership with the Sponsoring Institution, must design an effective program structure that is configured to provide residents/fellows with educational and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities.

Clinical and Educational Work Hours Monitoring

To fulfill its oversight responsibilities, the Graduate Medical Education Committee (GMEC) requires residents/fellows to submit work hours data in MedHub to monitor compliance. The GME Office generates MedHub work hours reports for GMEC’s review at a scheduled meeting. Residents/Fellows are required to continuously log clinical and educational work hours at least four (4) times per academic year, for a consecutive four-week period during each sampling cycle. The sampling periods occur during the following months:

1. August
2. October
3. February
4. April

Program directors may require more frequent logging (e.g., continuous logging) as needed. Clinical and educational work hours must be logged into MedHub for each required sampling period.

1. Data Acquisition
   1. Residents/Fellows must log work hours in real time in MedHub..
   2. Data acquisition should expand over a four-week period, a one-month period (28-31 days), or the duration of the rotation if it is shorter than four weeks.
2. Data Review
   1. Programs have access to review residents/fellows work hours submissions and comments in MedHub.
   2. Program compliance with work hours submission: during the reporting period, residents/fellows must demonstrate 80% or greater submission rate for work hours. It is the responsibility of the program to monitor submission rates. (MedHub Report – Work Hours Submission Report).
   3. Program compliance with work hours requirements: During and after the reviewed period, programs must review potential violations and consider schedule changes to reduce non-compliance.
   4. GMEC action: During its scheduled meeting, the GMEC will review MedHub work hours submissions and compliance reports. Programs found to be non‑compliant with the above parameters may, at the discretion of the DIO and GMEC, be required to submit an action plan outlining corrective actions to address identified work hours compliance issues.

Noncompliance with Work Hours

Programs that have clinical and educational work hours issues as demonstrated by internal and ACGME data, will be required to monitor work hours in a more stringent manner.

1. Accreditation Notification Letter
   1. Citation: Programs that receive a citation for work hours will be required to have residents/fellows log work hours daily and continuously, effective immediately and throughout the academic year or until the citation is resolved. GMEC will review the data quarterly and will release the program from reporting when satisfactory compliance has been met or when the citation is resolved.
   2. Area for Improvement (AFI): Programs that receive an AFI in work hours will continue to be monitored through on-going GMEC oversight procedures as determined by the DIO and GMEC Executive Committee (i.e. action plan)
2. GMEC-Initiated Monitoring
   Programs with recurrent or ongoing work hours concerns such as ACGME Resident/Fellow Survey, multiple action plans, or other metrics—may be required to implement daily and continuous resident/fellow work hours logging.

Program Director Authority

Program directors have the authority to require more stringent clinical and educational work hours reporting by residents/fellows that better suit their program. For example, small programs with fewer residents/fellows and rotations may have an “at-risk” rotation that falls outside the quarterly review periods. The program director has the authority to require the residents/fellows to record clinical and educational work hours on that rotation (e.g. pediatric nephrology fellow rotating on MICU in April)

Resident/Fellow Reporting

Residents/Fellows may report violations of the 80-hour requirement through procedures established by each program and/or by calling the Designated Institutional Official, UAB Hospital at (205) 934-4793; Director, Graduate Medical Education Department at (205) 934-4793; the GME Residents/Fellows’ Hotline at (205) 934-5025.  Such calls will be investigated and reported to the DIO.. Additional avenues of reporting provided by the Sponsoring Institution are the Corporate Compliance Office at 975-0585 and the Ethics Hotline 1-866-362-9476, or online www.uab.edu/ethics.

The GMEC will evaluate each program's compliance and may request that the program director describe, develop and implement corrective action for any rotations exceeding the 80-hour requirement, or otherwise identified as problematic.

Requests for Approval of Clinical and Educational Work Hours Exceptions

A Review Committee may grant rotation-specific exceptions for up to 10 percent or a maximum of 88 clinical and educational work hours to individual programs based on a sound educational rationale. In preparing a request for an exception, the program director must follow the clinical and educational work hours exception policy from the ACGME Manual of Policies and Procedures. The program director must submit a written request to the Chair, GMEC, which contains the following information:

1. Educational Rationale: The duration of the exception and the service assignments, rotations, and/or level(s) of training for which the exception is requested should be identified. The request must be based on a sound educational rationale and described in relation to the program’s stated goals and objectives for the particular assignments, rotations, and level(s) of training for which the increase is requested. Blanket exceptions for the entire educational program will be considered the exception, not the rule.
   1. required case experiences
   2. reasonable efforts to limit activities that do not contribute to enhancing resident/fellow education have already been made
2. Patient Safety: A description of how the program and institution will monitor, evaluate, and ensure patient safety with extended resident/fellow work hours.
3. Moonlighting Policy: Specific information regarding the program’s moonlighting policies for the periods in question must be included.
4. Call Schedules: Specific information regarding the resident/fellow call schedules during the times specified for the exception must be provided.
5. Faculty Monitoring: Evidence of faculty development/education activities regarding the effects of resident/fellow fatigue and sleep deprivation must be appended.
6. Current accreditation status of the program and of the Sponsoring Institution should be provided in the formal request.
   The GMEC must review and formally endorse the request for an exception, as noted above. The signature of the DIO shall indicate the endorsement of the request.

Fatigue Mitigation

Programs must educate all faculty members and residents/fellows on the following:

1. Recognizing the signs of fatigue and sleep deprivation
2. Alertness management and fatigue mitigation processes
3. Encourage residents/fellows to use fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning

In accordance with ACGME Common Program Requirement 6.15, the Hospital requires each training program to educate their residents/fellows and faculty in fatigue recognition as well as fatigue mitigation. The following are minimal requirements:

1. AMA lecture on fatigue recognition and mitigation.

Faculty awareness of fatigue recognition and mitigation

General

• Any resident/fellow that feels too fatigued to fulfill their clinical responsibilities will contact the supervising faculty member or the senior resident/fellow on service or on call.
• There will be no retaliation or unprofessional behavior toward any resident/fellow who is fatigued.
• The faculty member may work with the program director to call in another resident/fellow (if education of the resident/fellow will not be sacrificed) or the faculty member will cover the service.

Process for transition of patient care

See Transition of Care Policy.

Sponsoring Institution Resources

Transportation Options for Residents/Fellows Who May Be Too Fatigued to Safely Return Home: Each incoming resident/ fellow is sent an email invitation to join the GME Ride Uber account. By clicking the link in the invitation email, residents/fellows will be able to call an Uber when too fatigued to drive home or when dealing with car repairs. Please contact the Graduate Medical Education Department at gme@uabmc.edu or (205) 934-4793 with activation issues or questions. The Graduate Medical Education Department is open Monday – Friday from 7:00 a.m. – 5:00 p.m. If this service is needed outside GME Office business hours, pick up any hospital phone and call *55 (or, 934-3422), identify yourself as a GME resident/fellow and request this service. In addition, the Hospital has designated call rooms on clinical inpatient units.

GMEC Approved Date: June 2, 2026
Next Review Date: Spring 2027