Institution Responsibilities: Duty Hour Monitoring at the Institution Level Policy and Procedure

As the Sponsoring Institution for all ACGME accredited residency and fellowship programs, GME Administration is required to ensure that all programs are compliant with the duty hour requirements set forth by the ACGME as well as their specific Review Committees (RCs). GME Administration in conjunction with the Graduate Medical Education Committee (GMEC) monitors duty hour compliance as outlined below. 

 

In accordance with the GME policy “Updating and approving assignments and hours in the duty hours module of the Residency Management Suite (RMS)”, all trainees are required to use the RMS to update and approve their assignments and hours in the duty hours module for all training related activities.

 

GME Administration will extract reports from the data collected in RMS. A one month synopsis on each program will be presented to the GMEC on a monthly basis. Those programs with violations will be required to submit a written report to the GMEC outlining measures to be taken to correct the areas of non-compliance.   

 

Monitoring Compliance at the Institution Level

 

1)      GME Administration will run reports for each program from RMS every three months looking at a rotation-based timeframe.

2)      GME Administration will present a summary report to the GMEC outlining any violations that occurred. 

3)      Programs will be required provide a response to the violations to GME Administration prior to the GMEC meeting.

4)      Programs with duty hour violations will have to work diligently with their trainees and site directors to ensure violations do not occur.
 

Programs are questioned about duty hour compliance during the Internal Review. This information is then discussed during the confidential resident/fellow interview to confirm the accuracy of the information reported. If violations are reported by the trainees, programs will be required to provide a response to the GMEC.
 

GME Administration has an email link on the GME website that goes to the Associate Dean for Graduate Medical Education. This is a confidential venue for trainees to report any concerns they may have regarding their program. Violations reported will be investigated by GME Administration and acted upon accordingly.  

Email: gmedhv@umn.edu 
  

Each year the training programs update their program policy manuals. The programs use a template created by GME Administration which includes the development and updating of policies related to duty hours.
 

Each year the ACGME surveys all of the residents and fellows. Reported duty hour violations of 10% or higher require a response from the program. This response is reviewed by the GMEC prior to submission to the ACGME. 

 

The DIO will meet with the residents/fellows directly if serious duty hour violations are identified during any of the institution monitoring processes outlined above. The DIO and GME Administration will work with the program and the sites where the violations are occurring to get the issues resolved. 

 

Programs must monitor trainee duty hours on a regular basis to ensure any problems identified are addressed quickly. Programs are encouraged to use RMS to monitor duty hours. Programs who do not have an identified RMS super user should contact MMCGME services to learn about duty hour training opportunities.

 

Reviewed: 3.12