ACGME DUTY-HOUR REQUIREMENTS PER SPECIALTY

Accreditation Council for Graduate Medical Education (ACGME)

The ACGME’s Approach to Limit Resident Duty Hours 12 Months After Implementation:

A Summary of Achievements

Rationale for the Duty Hour Limits

Changes in health care delivery, and concerns that restricted sleep has a negative effect on performance

resulted in a need to limit resident duty hours. As the accrediting body for more than 7,900 residency

programs, the Accreditation Council for Graduate Medical Education is the entity charged with setting

and enforcing duty hour limits. In July 2003, ACGME instituted a comprehensive approach that includes:

(1) standards for resident hours and institutional oversight; (2) promoting compliance; and (3) increasing

knowledge on the effect of the standards and on innovative ways to conduct education and patient care

under limited resident hours. ACGME considers duty hour limits an important element of its

comprehensive approach to promote high-quality education and safe patient care.

The Standards

ACGME’s common duty hour standards acknowledge scientific evidence that long hours and sleep loss

have a negative effect on resident performance, learning and well-being.

The duty hour standards include:

• An 80-hour weekly limit, averaged over four weeks;

• An adequate rest period, which should consist of 10 hours of rest between duty periods;

• A 24-hour limit on continuous duty, and up to six added hours for continuity of care and education;

• One day in seven free from patient care and educational obligations, averaged over four weeks;

• In-house call no more than once every three nights, averaged over four weeks;

• The option for programs in some specialties to request an increase of up to 8 hours in the weekly

hours, if this benefits resident education, with approval by their sponsoring institution and the

Residency Review Committee (RRC) in the given specialty.

ACGME chose 80-hours as the upper limit to safeguard against the negative effects of chronic sleep loss,

and selected a limit of 24 hours plus up to six hours to address the effects of acute sleep loss, and to allow

for adequate time for patient hand-off and didactic learning.

Achievements in the first 12 Months

In the first 12 months after the July 2003 implementation, ACGME, the RRCs and the residency

education community rose to the challenge of applying the duty hour standards to 7,973 accredited

specialty and subspecialty programs. Programs and sponsoring institutions made changes in the clinical

training of residents, their patient care activities and the mechanisms for duty hour monitoring and

oversight. Many programs used schedule changes, night float and other rotation changes to bring duty

hours below the common limits. Others replaced resident services with care by nurse practitioners,

physician assistants or hospitalists. A few programs completely re-engineered their patient care and

education system to function well under reduced hours. Virtually all programs increased the clinical

responsibilities of faculty physicians. Highlights from the first year under the new standards include:

• ACGME collected data on duty hour compliance from the program directors of all accredited programs,

with more than 98% of ACGME-accredited programs responding by the March 2004 deadline. Senior

officials at each sponsoring institution verified this information.

• ACGME instituted systems to track compliance, including the number of programs cited for duty

hour violations, complaints related to resident hours, and programs applying for duty hour exceptions.

• During accreditation reviews conducted between July 2003 and June 2004, ACGME site visitors

interviewed program directors, faculty, residents and sponsoring institution representatives and

conducted primary reviews of documents that detail resident duty hours, including rotation schedules,

call rosters and some institutional duty hour surveys to verify compliance with the standards.

• Of the 2,235 programs reviewed during Academic Year 2003-04, 208 were applications for new

programs. Of 2,027 existing programs that received full reviews, 101 programs (5.0%) received one

or more citations related to non-compliance with the duty hour standards. The majority of citations

related to compliance with the 80-hour weekly limit (52 citations), followed by the requirement for

one day in seven free of program duties and the 24 + up to 6-hour limit on continuous duty (29 and 27

Accreditation Council for Graduate Medical Education, Report of the Work Group on Resident Duty Hours and

the Learning Environment, June 11, 2002; (http://www.acgme.org, accessed July 16, 2004).

citations, respectively). RRCs requested that 42 programs provide them with dedicated reports that

detail their efforts to bring duty hours into compliance or general progress reports that included

information on duty hours. Detailed information on duty hour citations, including duty hour citations

and time to next RRC review by specialty, is shown at Exhibit 1.

• ACGME interviewed between 11,000 and 13,000 residents during scheduled accreditation site visits,

and via an electronic resident survey collected data on duty hour compliance from 25,176 residents in

1,489 programs. Among the respondents, 834 residents (3.3% of the responding residents) in 370

programs (24.8% of responding programs) reported working more than 80 hours per week during the

previous 4 weeks. That a small group of residents work beyond the duty hour limits likely relates to

factors associated with individual residents’ learning and practice performance, rather than program

level non-compliance with the standards. At the same time, the survey found a few programs where

the majority of residents worked significantly beyond the duty hour limits. ACGME is following up

with programs where the resident survey data suggests a potential program-level compliance problem.

• ACGME received 53 complaints related to non-compliance related to resident hours. Eleven were

dismissed as unfounded. For the remainder ACGME instituted appropriate follow-up activities,

including its procedure for “Rapid Response to Alleged Egregious Accreditation Violations or

Catastrophic Institutional Events” for the most serious complaints. Details are shown at Exhibit 2.

• The RRCs approved 75 requests by individual programs to extend the weekly limit to 88 hours, and

denied another 14 requests. Exhibit 3 shows requests by specialty. ACGME denied a request by the

surgical RRCs to increase the weekly limit for the surgical chief resident year to 88 hours, due a lack

of data thus far showing a negative effect of the limits, and ability of programs to request an increase

in their weekly limit for chief residents to 88-hours, with the approval of their institution and RRC.

• Eleven RRCs have standards that are more restrictive than the common duty hour limits or do not

permit programs to apply for the increase in the weekly duty hour limit, as shown at Exhibit 4.

• ACGME communicated its approach to limit resident duty hours and its compliance efforts to the

academic community and the public through published articles, interviews and information presented

on the ACGME Web site and in the quarterly ACGME Bulletin.

• In August 2003, ACGME communicated with approximately 100,000 residents in accredited

programs through the officials at their sponsoring institution, informing them about the duty hour

standards and compliance monitoring activities, including residents’ rights to raise concerns about

violations of the standards with their institutions and, ultimately, ACGME.

• ACGME is sensitive to the issue that reporting alleged non-compliance with the standards may place

such “whistleblowers” at risk for retaliation or retribution, and its confidential complaint management

process and institutional requirements seek to safeguard these individuals. In addition, ACGME has

emphasized to program directors and institutional leaders the need to protect “confidential reporters,”

beginning with an article in the fall 2003 ACGME Bulletin.

• ACGME kept the academic community informed about compliance activities and “innovative ideas”

for meeting the standards thorough articles in the ACGME Bulletin, question and answer sections on

the ACGME Web site and presentations to the academic community. Successful approaches for

reducing hours that preserve a balance between education and service could be adopted or adapted by

other programs and institutions. A sampling of innovative ideas is presented at Exhibit 5.

Potential Future Refinements to the Standards

ACGME has solicited feedback on the elements of the standards that may reduce educational quality or

have other unintended effects, with the goal of assessing the need for future refinements. It is aware that

public attention is focused on the issue of resident hours and the mechanisms to ensure compliance and

believes that a period of at least 12 to 18 months without changes to the standards is needed to give

programs time to adapt education and patient care activities to the limits and to collect data on their effect.

ACGME may make future refinements in areas where key indices suggest the standards may be

problematic from an educational or patient care perspective. Revisions to the standards would be made

only in response to convincing data that they are necessary and would benefit education and/or patient

care, and after a process of soliciting broad input and support for any changes from the education

community and the general public.

Programs with Duty Hour Citations, July 1, 2003 – June 30, 2004 Exhibit 1

Specialty

No. of

programs

reviewed

No.

pro-

grams

cited

Cited

hours

per

week

Day

in 7

free

hour

rest

period

Con-

tinous

duty

24h + 6

Call no

than

every 3rd

night

Moon-

lighting

Total

Duty

Hour

Cita-

tions

Avg.

Cycle

Length

(1)

Avg.

Total

Citat-

ions

(1)

Duty Hour

Reports

Requested

Allergy and Immunology 21 3 14.3% 3 3 1.0 7.7 0

Clin. Lab. Immunol. 10 0 0.0% 0 -- -- --

Anesthesiology 41 2 4.9% 2 2 2.5 8.5 2

Anesth. Subspec. 52 5 9.6% 5 5 3.7 6.2 2

Colon and Rectal Surgery 10 0 0.0% 0 -- -- --

Dermatology 26 0 0.0% 0 -- -- --

Dermatology Subspec. 14 0 0.0% 0 -- -- --

Emergency Medicine 29 1 3.4% 1 1 4.0 6.0 0

Emerg. Med. Subspec. 19 0 0.0% 0 -- -- --

Family Practice 154 26 16.9% 10 4 3 14 1 1 33 3.4 10.3 5

Family Practice Subspec. 35 0 0.0% 0 -- -- --

Internal Medicine 109 14 12.8% 10 3 3 1 3 1 21 2.4 11.6 0

Internal Med. Subspec. 329 10 3.0% 4 5 1 1 11 2.8 6.7 0

Medical Genetics 12 1 8.3% 1 1 -- -- --

Molec. Genetic Pathol. 4 0 0.0% 0 -- -- --

Neurological Surgery 17 0 0.0% 0 -- -- --

Neurology 29 2 6.9% 1 1 2 2 6 3.3 6.0 1

Neurology Subspecialties 37 0 0.0% 0 -- -- --

Nuclear Medicine 13 0 0.0% 0 -- -- --

Obstetrics and Gynecology 69 4 5.8% 1 1 2 4 3.0 13.5 0

Ophthalmology 34 0 0.0% 1 1 2 5.0 3.0 0

Orthopaedic Surgery 57 3 5.3% 2 1 3 3.7 4.0 0

Ortho. Surg. Subspec. 28 0 0.0% 0 -- -- --

Otolaryngology 29 0 0.0% 0 -- -- --

Otolaryngology Subspec. 6 0 0.0% 0 -- -- --

Pathology 41 0 0.0% 0 -- -- --

Pathology Subspec. 67 2 3.0% 2 2 -- 4.0 0

Pediatrics 41 2 4.9% 1 1 2 5.0 5.0 1

Pediatrics Subspecialties 120 4 3.3% 2 2 1 1 1 7 3.3 6.5 1

Phys. Med. & Rehab. 20 0 0.0% 0 -- -- --

PM and R Subspec. 6 0 0.0% 0 -- -- --

Plastic Surgery 44 2 4.5% 2 1 1 1 1 6 4.0 1.0 1

Plastic Surgery Subspec. 7 0 0.0% 0 -- -- --

Preventive Medicine 17 1 5.9% 1 1 4.0 6.0 0

Prev. Med. Subsp. 2 0 0.0% 0 -- -- --

Psychiatry 44 1 2.3% 1 1 5.0 1.0 0

Psychiatry Subspecialties 51 1 2.0% 1 1 5.0 4.0 0

Radiation Oncology 20 0 0.0% 0 -- -- --

Diagnostic Radiology 50 0 0.0% 0 -- -- --

Diagn. Radiol. Subspec. 93 0 0.0% 0 -- -- --

General Surgery 63 2 3.2% 2 1 1 4 3.0 2.3 2

General Surgery Subspec. 65 1 1.5% 1 1 4.0 5.0 0

Thoracic Surgery 31 3 9.7% 3 1 1 1 1 1 7 3.7 6.0 0

Transitional Year 30 9 30.0% 3 3 3 9 2.5 7.2 0

Urology 27 2 7.4% 3 0 -- -- --

Urology Subspecialties 4 0 0.0% 0 -- -- --

Overall Citations

2027 101 5.0% 52 29 12 27 9

135 3.3 7.3 15

Exhibit 2

Complaints about Alleged Non-Compliance with the Duty Hour Standards

and their Disposition

July 1, 2003 through June 30, 2004

Specialty

No. o

Complaints

% of all

Complaints

Residents in

specialty

% of all

residents

Internal Medicine 15 28.3% 21,675 21.6%

Pulmonary/Critical Care Medicine 2 3.8% 1,174 1.2%

Gastroenterology 1 1.9% 1,163 1.2%

General Surgery 7 13.2% 7,452 7.4%

Orthopaedic Surgery 4 7.5% 3,085 3.1%

Obstetrics Gynecology 3 5.7% 4,674 4.7%

Family Practice 3 5.7% 9,869 9.8%

Diagnostic Radiology 3 5.7% 4,117 4.1%

Anesthesiology 2 3.8% 4,921 4.9%

Pediatrics 2 3.8% 7,796 7.8%

Psychiatry 2 3.8% 4,682 4.7%

Child and Adolescent Psychiatry 1 1.9% 706 0.7%

Emergency Medicine 2 3.8% 3,980 4.0%

Transitional Year 2 3.8% 1,275 1.3%

Neurology 1 1.9% 1,478 1.5%

Neurosurgery 1 1.9% 747 0.7%

Plastic Surgery 1 1.9% 466 0.6%

Thoracic Surgery 1 1.9% 310 0.3%

Total, Specialties with complaints 53 100.0% 79,570

esidents in Specialties without duty hour complaints 0 20,944

Grand Total 53 100,514 .05%

Disposition of Complaint Number

% of all

complaints

Monitor at time of next site visit 14 26.42%

Site visit scheduled 10 18.87%

Disposition pending 6 11.32%

Reviewed by RRC without a site visit 5 9.43%

Requested progress report 4 7.55%

Proposed Probation 1 1.89%

Confirmed Probation 1 1.89%

Program warned and time to site visit shortened 1 1.89%

Complaint dismissed as unfounded 11 20.75%

Total 53 100.00%

Exhibit 3

Requests for Extend the Weekly Limit to 88 Hours

By Specialty: Total Number of

Programs

Requests for Duty Hour Exceptions

Requested Denied Approved

Allergy and Immunology (1) 83

Anesthesiology (1) 324

Colon and rectal surgery 37 0

Dermatology (1) 155 0

Emergency Medicine (1) 163

Family Practice (1) 569

Internal Medicine (1) 1,842

Medical Genetics (1) 58 0

Neurological surgery 95 41 7 34

Neurology (1) 301

Nuclear medicine 64

Obstetrics and Gynecology 254 6 5 1

Ophthalmology 120 0

Orthopaedic Surgery (1) 331 8 0 8

Otolaryngology (1) 118 2 0 2

Pathology (1) 507 0

Pediatrics (1) 842

Phys. Med. And Rehabilitation (1) 106 0

Plastic Surgery (1) 108 0

Preventive Medicine (1) 86

Psychiatry (1) 446

Radiation oncology 77 0

Radiology - Diagnostic (1) 464

Surgery - General (1) 461 23 5 18

Thoracic surgery 92 11 0 11

Urology (1) 139 1 0 1

Transitional year 131 0

Totals 7,973 92 17 75

Shaded: RRC does not permit an increase to 88 weekly hours

(1) Includes subspecialty programs

Source: ACGME Accreditation Database, June 2004

Exhibit 4

Specialty-Specific Duty Hour Requirements that Exceed the Common Duty Hour Requirements

July 1, 2003

Allergy and Immunology: V.F.6. The RRC for Allergy & Immunology will not consider requests for an

exception to the limit to 80 hours per week, averaged monthly.

Anesthesiology: V.F.3.b: During the 6 additional hours (after the end of the on-call period), residents may not

administer anesthesia in the operating room for a new operative case or manage new admissions to the ICU. The

resident should not manage non-continuity patients in the 6 hours post-call.

V.F.2.d. The RRC will not consider requests for a rest period of less than 10 hours.

V.F.6. The RRC for Anesthesiology will not consider requests for an exception to the limit to 80 hours per week,

averaged monthly.

Emergency Medicine: IV.A. 7.a.2) While on duty in the emergency department, residents may not work longer

than 12 continuous scheduled hours. There must be at least an equivalent period of continuous time off between

scheduled work periods.

IV.A. 7.a. 3) A resident should not work more than 60 scheduled hours per week seeing patients in the emergency

department and no more than 72 duty hours per week. Duty hours comprise all clinical duty time and conferences,

whether spent within or outside the educational program, including all on-call hours.

V.F.6. The RRC for Emergency Medicine will not consider requests for an exception to the limit to 80 hours per

week, averaged monthly.

Family Practice: V.F.2.d. The RRC will not consider requests for a rest period of less than 10 hours.

V.D.6. The RRC for Family Practice will not consider requests for an exception to the limit to 80 hours per week,

averaged monthly.

Internal Medicine: In-house call must occur no more frequently than every third night (this standard does not

permit averaging the frequency of in-house call).

V.D.6. The RRC for Internal Medicine will not consider requests for an exception to the limit to 80 hours week,

averaged monthly.

Neurology: V.F.6. The RRC for Neurology will not consider requests for exceptions to the limit to 80 hours per

week, averaged monthly.

Nuclear Medicine: V.F.6. The RRC for Nuclear Medicine will not consider requests for exceptions to the limit to

80 hours per week, averaged monthly.

Pediatrics: V.F.6. The RRC for Pediatrics will not consider requests for exceptions to the limit to 80 hours per

week, averaged monthly.

Preventive Medicine: V.F.6. The RRC for Preventive Medicine will not consider requests for an exception to the

limit to 80 hours per week, averaged monthly.

Psychiatry: V.F.6. The RRC for Psychiatry will not consider requests for exceptions to the limit to 80 hours per

week, averaged monthly.

Diagnostic Radiology: V.F.6. The RRC for Diagnostic Radiology will not consider requests for exceptions to the

limit to 80 hours per week, averaged monthly.

Exhibit 5

Selected Innovative Approaches

Internal Medicine: Reducing Internal Medicine Duty Hours at the University of Virginia

In March of 2002, information on resident hours at this major university teaching hospital showed that

25% oft the residents worked more than 80 hours per week. A volunteer resident task force developed

options to bring the program into compliance and the residents chose a plan which maintained a schedule

of call every fourth night, but mandated that one member of the intern-resident team go home at 10 pm,

when the admitting cycle ended. This schedule resulted in residents taking overnight call every eight

night, and decreased the percentage of residents working over the 80-hour limit from 25% to 8%.

To bring all residents into compliance, an additional day off was added to each four-week ward block.

Each team member takes off Thursday or Friday during the week the team has Saturday call. This adds a

fifth day off to each four-week inpatient rotation and produced 100% compliance with the duty hour

limits. It also maintains continuity of care. Since the implementation of this plan, documented attendance

at conferences has not decreased, suggesting that the structured educational experiences have not been

affected by the changes in residents’ scheduling patterns.

Neurological Surgery: The Neurological Surgery Program at the University of Florida

In this neurological surgery program, faculty and residents have worked together to create and refine a

system that complies with the common duty hour requirements, while preserving and maximizing the

educational mission of the residency program. To make up for the reduced availability of residents the

department hired nurse practitioners (NPs) for each of two services where residents train. Despite the

added financial burden, the NPs have worked out well. They handle many of the less “educational”

aspects of residency, such as routine consults, preoperative histories and physicals, routine labs, lumbar

punctures and discharge orders. Patient and family satisfaction has increased significantly, especially in

the area of discharge teaching. The department has also begun to include residents who are off service or

in the laboratory in the call rotation, and has moved to home call for chief residents who back up junior

residents, and for two clinical services that are smaller and have less medical acuity.

Residents are required to complete and return a weekly time card. A few residents were caught falsifying

their time cards early in this process, and the department informed them that severe consequences would

follow if duty hours were not accurately reported. The program director and all residents meet monthly to

discuss duty hour issues, and explore the need for adjustments to the system.

Neurology: Reducing Neurology Resident Hours at UT Medical Branch, Galveston

In early 2003, this neurology program revised its resident scheduling patterns to conform to the ACGME

duty hour limits. The program’s nine residents all take night call with no differences between senior and

junior residents. Rotating residents do not participate in call. At the heart of the system is that each

resident is scheduled for a two-week long “night float” rotation three times per year. The other residents

are on a regular rotation with more limited call. No resident works more than 80 hours per week or 24

hours of continuous duty. The primary benefit is that residents no longer complain of being “post-call”

and do not fall asleep in conferences. Residents and faculty consider the plan a success.

Surgery: Models for Surgical Resident Education at Northwestern University, Chicago

A think tank at the McGaw Medical Center of Northwestern University developed four resident rotation

models the surgery residency program currently uses. The goal was to develop models programs can

adopt to comply with the standards while maintaining or enhancing resident education. In the Stretch

Model, residents take call every fourth night (or less) and leave the next morning. This is the easiest

approach to get to an 80-hour week, but it has no real educational advantages other than reducing duty

hours, presumably giving residents more time to read. The Night Float Model consists of a traditional

resident team system, except that a percentage of the program's residents are designated to a “night-float”

shift, usually for a month at a time. Each resident rotates on night float two to three months per year. The

day team has one hour of overlap with the night- float team to allow for a robust "sign-out." Teams

working during the day would take no in-house night call. The "night float" team works a night shift six

days per week, although larger programs may be able to accommodate a five nights per week schedule.

The Apprentice Model involves one resident working exclusively with one or two faculty members over

several months. Residents work side-by-side with their mentors in the operating room and outpatient

setting and take home call when their mentor is on call, and participate only in the care of their mentors'

patients. Faculty members are selected carefully based on dedication to education and an appropriate

practice profile. This model lends itself well to subspecialty areas like colorectal or breast surgery, but

also can be used for general surgery rotations. Apprentices take no in-house call, and are on duty less than

80 hours, even if they have to come in at night once or twice a week. In the Mastery (Case-Based) Model,

cases are assigned to residents solely based on their learning needs. Knowledge and skills associated with

diagnoses and operations are measured by personal progress, not by time. Proficiency is verified through

formal assessment, and residents are allowed to advance to other areas and are not required to scrub on

operations they have mastered unless they want to refresh their knowledge. Residents are responsible for

making arrangements to review the cases with the appropriate attending. They round on their own

patients in the morning and go to the clinic or operating room depending on their assignments for that

week. They are not required to take night call, but could take call from home. Learning expectations are

made clear at the start and are mastery-based, but broken down by year of training for planning purposes.

Surgery: From more than 110 to less than 80 hours at St. Luke’s Hospital, Bethlehem

After analyzing the responsibilities and tasks of its residents and the service requirements of their various

clinical rotations, the leadership of this surgery program instituted a modified night float system. From

Sunday through Thursday one resident is on a night-float rotation from 6 pm to 8 am and to 11 am for

Friday morning conferences. Two different residents are on call Friday night, Saturday day and night, and

Sunday during the day. The night-float resident changes weekly. Chief residents take call from home and

come to the hospital when needed.

The modified night float system has advantages in a small surgery program: (1) residents miss few

clinical opportunities; (2) residents are able to attend surgical clinics and attending faculty office hours;

(3) residents can participate in time-protected conferences during the morning; (4) residents have more

time for rest and personal learning; (5) the night float resident is still involved in operative procedures in

that he/she participates in late elective surgical cases and is involved in emergency surgical cases at night.

Making the modified night float system a success requires a commitment by the faculty, nursing and

administration to make the residency primarily an educational experience. It also requires understanding

on the part of residents and faculty that the ACGME duty hour standards improve the educational

experience of residents. Finally, a robust sign-out of patients at the beginning and end of the night-float

period is a key element of a successful night-float model.