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Section 6: Duty Hours and Moonlighting Policies

6: DUTY HOURS POLICY

6.A: Resident Duty Hour Policy
      6.A.01: Transportation Option for Residents to Return Home Safely
      6.A.02: Duty Hour Reporting for Residents on Off-Service Rotations
      6.A.03: Duty Hour Extensions
    
     6.B: Resident Moonlighting Policy
    
     6.C: Resident Professional Fee Billing Policy

Definitions:

“Resident” means a physician in an Accreditation Council for Graduate Medical Education (ACGME) accredited Emory Training Program for a clinical specialty.  Unless otherwise specified, “resident” includes fellows in an ACGME accredited Emory Training Program for a clinical subspecialty.  Emory residents or fellows in non-accredited training programs or those accredited by other organizations such as member boards of the American Board of Medical Specialties should be considered included in these policies if their salaries are managed by the Emory Office of Graduate Medical Education or unless specifically excluded by the Emory Graduate Medical Education Committee (GMEC) or Associate or Assistant Dean for GME (the Designated Institutional Officials or “DIO”).

6.A Resident DUTY HOURS POLICY

The GMEC follows guidelines established by the ACGME regarding the clinical learning environment including those related to duty hours for residents in accredited training programs as defined in the ACGME Common Program Requirements (CPR). Duty 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 in-house during call activities, and scheduled activities such as conferences. 

General Guidelines

1. Residents are responsible for accurately reporting their duty hours, including all time spent in Internal and External Moonlighting, per program requirements, and for honestly reporting concerns of non-compliance.

2. Program Directors are responsible for monitoring and enforcing compliance with duty hour guidelines.

3. If specialty/subspecialty-specific program requirements for duty hours as defined by an individual ACGME Review Committee (RC) are more restrictive than the CPR, then the duty hour requirements of that RC will apply for residents in that specialty/subspecialty program and will supersede the CPR.

4. Concerns regarding duty hours may be reported to the Associate or Assistant Dean for GME
or through the Confidential Helpline 1-888-594-5874. Concerns may be reported anonymously.

Specific Guidelines

The ACGME duty hour requirements are found within the CPR on the ACGME web site (https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_07012016.pdf, accessed 01/03/2017).   The 2011 ACGME guidelines are summarized in appendix D.1 below, but Emory programs are required to follow the most recently approved ACGME version of the CPR.

All programs must have policies for duty hours that at a minimum meet the ACGME's institutional and program requirements. Programs must monitor in-house and from-home duty hours on an ongoing basis in a way that provides accurate data.  The GMEC Duty Hour Subcommittee (“Subcommittee”) has established reporting requirements, one of which is that each monitoring period must be 4 weeks in length, not a moving average or extrapolated from a shorter length of time.  With GMEC oversight, the DIO and the Chair of the Subcommittee will review program data resulting from internal reviews, annual administrative processing sessions, random audits and other times as determined by the DIO, the GMEC or by the Duty Hours Subcommittee.  If a program has received approval from the ACGME to extend the 80-hour weekly duty hour limit, if the program received a duty hour citation or if an internal review reveals a duty hour issue, then these training programs must send reports to the sub-committee at a minimum of every other month. 

Program Directors must monitor call-from-home duty hours in terms of frequency and characteristics to assure that residents and fellows are following basic guidelines established by the ACGME.

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6.A.01: Transportation Option for Residents Too Fatigued to Return Home Safely

For residents/fellows who may be too fatigued to drive home, the GME Office has arranged for residents/fellows' transportation home with a next day return trip through the Checker Cab Company.

Residents can call Checker Cab (404-351-1111) and give their specific pick up location. PLEASE NOTE: 1) The Taxi driver will pick up from any affiliated training site at which residents/fellows are rotating and 2) Checker Cab is authorized to only drop off at a residential address. Resident must indicate they are on the Emory Authorized Caller List and with the Emory GME Account. The GME Office will cover the cost of the transportation (including the tip).

Residents must print their name and program name clearly on the voucher provided by the cab driver. The voucher will be used to bill the GME Office. Checker Cab is authorized to provide a return trip the next day to the pickup location. The Program Director or Supervising Attending should be made aware if a resident/fellow is too fatigued to drive their vehicle and needs transportation.

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6.A.02: Duty Hour Reporting for Residents on Off-Service Rotations

This section of the Duty Hour Policy aims to establish a process that will address duty hour compliance in a rapid and timely manner when a resident is rotating onto another Emory ACGME training program’s clinical service (off-service rotations).  Problems regarding compliance with duty hour guidelines should be reported to the Chief Resident of the accepting training program.  If the Chief Resident does not respond to the report of noncompliance, then the resident must make a report to the Program Director of the sending program.  The Program Directors of the two programs must address the issues that led to the violation of the guidelines.  The resident may escalate notification to the GME Office at any time, as must the Program Directors if a timely resolution is not established.  When escalated to GME, the Associate Dean for GME will report to the Chairs of the two training programs and has the option of reporting to the Dean if the issues are not settled in a timely manner.

The GME office maintains a direct phone line to receive confidential complaints about all issues including duty hours. This phone number 1-888-594-5874 is private and secure.  The Associate or Assistant Dean for GME will respond to the recorded messages as appropriate.

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6.A.03: Duty Hour Extensions

On occasion, individual programs could determine a need to extend the ACGME’s 80-hour work week requirement rule up to a maximum of 10% above the current limit or a total of 88 hours per week, in accordance with ACGME requirements. This extension must be approved by the Emory GMEC.  If the request to extend work hours has been approved by the GMEC, then Program Directors must petition their specialty RC for permission to extend hours. The letter from the GMEC must be used when communicating to the RC.

Program Directors must use the following guidelines to petition the GMEC.

  1. Program Directors requesting an extension of duty hours must do so in writing to the Associate Dean for GME.
  2. Exceptions will only be considered for specific rotations.  Blanket exceptions for a duty hour exemption will not be considered.
  3. The letter must include the following information:
    1. A description of the resident's work week to delineate specific problem areas,
    2. A clear explanation of why the program cannot maintain the 80-hour limit,
    3. A clarification of the RC requirements the program will not meet if residents work 80 or fewer hours,
    4. Planned monitoring procedures to assure that residents will not work greater than 88 hours per week,
    5. Information describing how the program will monitor, evaluate and ensure patient safety with extended resident work hours,
    6. A sound educational rationale that should relate to the program's stated goals and objectives for the particular assignments, rotations and levels of training for which the increase is requested,
    7. The program's moonlighting policies and how the program will assure that it is accounting for these hours,
    8. Call schedules for the rotation in question and
    9. Evidence of faculty development activities regarding the effects of residents fatigue and sleep deprivation.
  4. The Subcommittee will serve as the committee to review requests for extensions of duty hours. The Associate Dean will review the membership of the Subcommittee to assure that conflicts of interest do not enter the decision process.
  5. The written findings and recommendations of the Subcommittee will be presented at the next regularly scheduled meeting of the GMEC.
  6. Members of the GMEC, based on the letter from the Program Director and the findings and recommendations of the Subcommittee, will develop its report and send this report to the Program Director.
  7. The decision of the GMEC is final.
  8. Program Directors will not implement the extension of duty hours until approved by the appropriate ACGME Review Committee.
  9. Program Directors must monitor resident work hours on a more intense basis if the ACGME has granted an extension.

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6.B. MOONLIGHTING POLICY

"Moonlighting" refers to a service performed by a resident, usually in the capacity of an independent physician, completely outside the scope of their residency-training program.

"External moonlighting" refers to moonlighting at a non – Emory affiliated institution 

"Internal moonlighting" refers to moonlighting within an Emory Healthcare or Emory University affiliated facility. External and internal moonlighting hours must be counted toward the 80-hour duty hour limit.

Residents are never required to engage in moonlighting.

Residents are prohibited from external or internal moonlighting without the prior written approval of the Program Director or his/her designee. The requirements necessary for such approval are set forth below under "External Moonlighting" and "Internal Moonlighting."

Residents have insurance coverage through Emory’s Liability Insurance Program for approved internal moonlighting services.

Moonlighting activities must be compatible with a resident’s visa status.

In addition to the requirements below, the Program Director or his/her designee's decision to approve or deny a resident's request to moonlight will depend on a number of factors including, but not limited to, interference with the resident's responsibilities in the training program and the individual circumstances of the resident.

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6.B.01: External Moonlighting Requirements:

1. The Resident must submit a written request for approval to externally moonlight by completing the "Request to do External Moonlighting" form.

2. To be considered for external moonlighting, the resident must meet the following requirements:

a. Residents must obtain a signed contract with the external facility and provide a copy of the signed contract to the Program Director. The contract must state that the facility will provide professional liability insurance coverage for the resident's moonlighting services and that the resident has received privileges. If the external facility does not provide insurance coverage, residents must obtain their own professional liability insurance, for no less than limits of $1mm per claim and $3mm in the annual aggregate, and provide proof of such insurance to the Program Director before moonlighting begins.

b. Residents must be fully licensed to practice medicine in the state where the moonlighting will occur. A residency-training permit is not a license to practice medicine outside the scope of residency training.

c. Residents on J-1/H1B Visas are prohibited from external moonlighting.

d. Residents must not wear Emory badges or Emory identifiers when moonlighting externally.

e. External moonlighting counts toward the duty hour limits set by the ACGME. The Program Director is expected and required to assess the resident's progress in the program and require the resident to stop moonlighting if performance does not reach an expected level. The resident must be aware of these expected levels of academic and clinical performance before beginning the moonlighting experience.

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6.B.02: Internal Moonlighting Requirements:

1. The Resident must submit a written request for approval to moonlight within Emory Healthcare facilities, Grady Hospital, Children’s Healthcare Of Atlanta (Children’s) hospitals and the Veterans Administration Medical Center (VAMC) by completing the "Request to do Internal Moonlighting" form. Emory’s Liability Insurance Program provides malpractice insurance for residents who moonlight within Emory facilities.

2.  To be considered for internal moonlighting, the resident must meet the following requirements:

a. When residents are moonlighting in any of the hospitals used by Emory’s training programs (i.e., Emory Healthcare facilities, Grady Hospital, Children’s Hospitals and the VAMC), billing practices must conform to Federal Center for Medicare and Medicaid Services (CMS) regulations as defined in policy 6.C: Resident Professional Fee Billing Policy.

b. Residents must be fully licensed to practice medicine in the State of Georgia. A residency-training permit is not a license to practice medicine outside the scope of residency training, even within an Emory-affiliated facility.

c. Residents on J-1/H1B Visas are prohibited from internal moonlighting.

d. Residents must assure the Program Director in writing that the total hours in residency training and the moonlighting commitment DO NOT EXCEED the limits set by the ACGME.

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6.C. Resident Professional Fee Billing Policy

Federal regulations and  CMS have established rules governing the payment for services performed by residents who are in an approved training program based on the setting where the services are performed (42 CFR 415.208, appendix D.2 below).  Medicare regulations include “ACGME fellow” in its definition of resident.  Approved training programs include those resident training programs approved by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS).  Emory University School of Medicine (EUSOM) GME will follow the Medicare billing rules and some additional Emory-specific requirements for all payers unless a specific exception is granted for a specific resident in circumstances where their training is not funded by CMS.

In most cases, a resident may not bill for professional services when working in an Emory-affiliated facility.  Whether a resident physician may bill for professional or patient care activities and what conditions apply to that billing activity depends on the location where the activities are performed and the resident’s funding source. The resident must also have the appropriate hospital and managed care plan credentialing necessary for billing.

For residents funded through traditional Federal CMS Direct Medical Education (DME)/Indirect Medical Education (IME) hospital payments at EUSOM affiliated institutions (including Emory Healthcare, Grady Health System, Children’s and the Atlanta VAMC), the resident may bill for patient care services only if:

  1. The activity is not in the same subspecialty as the resident’s Emory training program and is outside the scope of the resident’s residency training,
  2. The activity takes place only in the Emergency Department or in an outpatient setting, and
  3. The resident complies with the EUSOM Moonlighting policy.

For residents funded through non-traditional (non-CMS) sources at EUSOM-affiliated institutions, the resident may bill for professional or patient care activities only if:

  1. The activity is not in the same specialty or subspecialty as the resident’s Emory training program and outside the scope of the resident’s residency training,
  2. The resident complies with the Moonlighting policy, and
  3. The resident’s moonlight and eligibility to bill for patient services is individually approved by the Assoc/Assist Dean for GME.

For residents at non-affiliated institutions (outside the Emory training hospitals), the resident may bill for patient care services only if:

  1. The activity is not part of the resident’s residency training
  2. The resident complies with the Moonlighting policy.

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