Policies,Administrative,UWHC,Department Specific,Graduate Medical Education (GME)

Work Hours and Moonlighting (43.27)

Work Hours and Moonlighting (43.27) - Policies, Administrative, UWHC, Department Specific, Graduate Medical Education (GME)


Graduate Medical Education Departmental Policy

Policy Title: Work Hours and Moonlighting
Effective Date: October 18, 2017
Version: New

The purpose of this policy is to ensure compliance with all ACGME clinical experience and
work hour requirements. Programs, in partnership with UW Health, are expected to provide a
clinical learning environment that serves the best interests of both patients and residents, by
providing a structure that not only enables residents to gain the requisite educational and clinical
experience but also provides reasonable opportunities for rest and personal activities. The intent
of these requirements is to ensure that programs recognize the need to balance educational
experiences with time away from the program. If an imbalance exists, it is expected that the
program makes adjustments as needed.
In addition, residents and faculty members must demonstrate an understanding and acceptance of
their personal role in:

A. the safety and welfare of patients entrusted to their care;
B. patient and family-centered care;
C. their fitness for duty;
D. management of their time before, during, and after clinical assignments;
E. recognition of impairment, including illness and fatigue, in themselves and in their
peers; and
F. honest and accurate reporting of work hours, patient outcomes, and clinical experience


This policy applies to all Graduate Medical Education (GME) programs sponsored by UW


A. “ACGME” means Accredited Council for Graduate Medical Education.
B. The term “resident” refers to residents and fellows.
C. Program(s) will refer to ACGME-accredited program(s) sponsored by UW Health.
D. UW Health: For the purpose of this policy, the term “UW Health” shall mean University
of Wisconsin Hospitals and Clinics Authority, which is the sponsoring institution of the
ACGME-accredited training programs. “UW Health” is the trade name of University of
Wisconsin Hospitals and Clinics Authority and its affiliates.

E. “Work hours” (formerly known as duty hours) shall mean all clinical and academic
activities related to the residency/fellowship program. This includes inpatient and
outpatient clinical care, in-house call, short call, night float and day float, transfer of
patient care, and administrative activities related to patient care, such as completing
medical records, ordering and reviewing lab tests, and signing orders. Work hours also
include time spent participating in moonlighting and other scheduled activities, such as
conferences, call from home, and time spent in the hospital after being called in to
provide patient care. Types of work from home that must be counted include using an
electronic health record and taking calls. Hours spent on activities that are required in the
accreditation requirements, such as membership on a hospital committee, or that are
accepted practice in residency/fellowship programs, such as residents’ participation in
interviewing residency candidates, must be included in the count of clinical and
educational work hours.
F. Moonlighting: Compensated, medically-related work not related to training program

IV. POLICY (with excerpts from ACGME Common Program Requirements)

Programs will ensure compliance with ACGME requirements as outlined below:

A. Maximum Hours of Clinical and Educational Work per Week:
Work hours must be limited to 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. (CPR VI.F.1.) Reading done in preparation for the following day’s cases,
studying, and research done from home do not count toward the 80 hours.
Averaging must occur by rotation. This is done over one of the following: a four-week period; a
one-month period (28-31 days); or the period of the rotation if it is shorter than four weeks.
When rotations are shorter than four weeks in length, averaging must be made over these shorter
assignments. This avoids heavy and light assignments being combined to achieve compliance.
If a resident takes vacation or other leave, the ACGME requires that vacation or leave days be
omitted from the numerator and the denominator for calculating clinical and educational work
hours, call frequency, or days off. The requirements do not permit a “rolling” average, because
this may mask compliance problems by averaging across high and low clinical and educational
work hour rotations. The rotation with the greatest hours and frequency of call must comply with
the common clinical and educational work hour requirements.
B. Mandatory Time Free of Clinical Work and Education
Residents should have eight hours off between scheduled work periods. (CPR VI.F.2.b)) There
may be circumstances when residents 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. (CPR VI.F.2.b).(1))
Residents must have at least 14 hours free of clinical work and education after 24 hours of in-
house call. (CPR VI.F.2.c))

Residents must be scheduled for a minimum of one day in seven free of clinical work and
required education (when averaged over four weeks). The ACGME defines one day as “one
continuous 24-hour period free from all administrative, clinical and educational activities.” At-
home call cannot be assigned on these free days. (CPR VI.F.2.d))
C. Maximum Clinical Work and Education Period Length
Clinical and education work periods for residents must not exceed 24 hours of continuous
scheduled clinical assignments. (CPR VI.F.3.a))
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. (CPR VI.F.3.a).(1))
Additional patient care responsibilities must not be assigned to a resident during this time. (CPR
D. Clinical and Educational Work Hour Exceptions
In rare circumstances, after handing off all other responsibilities, a resident, on their own
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, or humanistic attention to the
needs of a patient or family, or to attend unique educational events. (CPR VI.F.4.a)(1)-(3))
These additional hours of care or education will be counted toward the 80-hour weekly limit.
(CPR VI.F.4.b))
E. Moonlighting
The primary responsibility of the resident is to the care of his/her patients. Moonlighting must
not interfere with the ability of the resident to achieve the goals and objectives of the educational
program, and must not interfere with the resident’s fitness for work nor compromise patient
safety. (CPR VI.F.5.a)) Time spent by residents in internal and external moonlighting (as
defined in the ACGME Glossary of Terms) must be counted toward the 80-hour maximum
weekly limit. (CPR VI.F.5.b)) All moonlighting hours must be logged in MedHub as part of the
weekly work hours. UW Health does not provide any liability coverage for moonlighting
activities (internal or external). The resident or the employer where the moonlighting takes place
must provide liability coverage for the moonlighting activities. Restrictions:

ξ PGY-1 residents are not permitted to moonlight. (CPR VI.F.5.c))
ξ Programs may not require residents to moonlight.
ξ The State of Wisconsin Medical Examining Board requires residents moonlighting in
patient care outside of their training program have a full, unrestricted medical license.
ξ Clinical moonlighting within UW Health will only be approved if:
o The resident meets and obtains UW Health Medical Staff requirements for
privileging; and
o The services furnished can be separately identified from those services that are
required as part of the training program. If distinguishable, there may still be
restrictions on allowable billing for inpatient services. These concerns will be

resolved by the clinical department with which the moonlighting appointment
originates and the UW Health Compliance Department.

F. In-House Night Float
Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.
(CPR VI.F.6.)
G. Maximum In-House On-Call Frequency
Residents must be scheduled for in-house call no more frequently than every third night (when
averaged over a four-week period). (CPR VI.F.7.)
H. At-Home Call
Time spent on patient care activities by residents on at-home call must count towards the 80-hour
maximum weekly limit. The frequency of at-home call is not subject to the every third-night
limitation, but must satisfy the requirement for one day in seven free of clinical and educational
work, when averaged over four weeks. (CPR VI.F.8.a)) At-home call must not be so frequent or
taxing as to preclude rest or reasonable personal time for each resident. (CPR VI.F.8.a).(1))
Residents are permitted to return to the hospital while on at-home call to provide direct care for
new or established patients. These hours of inpatient care must be included in the 80-hour
weekly maximum. (CPR VI.F.8.b))
I. Resident Time Off
Residents must be given the opportunity to attend medical, mental health, and dental care
appointments, including those scheduled during their working hours. (CPR VI.C.1.d.(1))
In addition, there are circumstances in which residents may be unable to attend work, including
but not limited to fatigue, illness, and family emergencies. Each program must have policies and
procedures in place that ensure coverage of patient care in the event that a resident may be
unable to perform their patient care responsibilities. These policies must be implemented
without fear of negative consequences for the resident who is unable to provide the clinical work.
(CPR VI.C.2.)
J. Fatigue Mitigation
Programs must educate all faculty members and residents to recognize the signs of fatigue and
sleep deprivation; educate all faculty members and residents in alertness management and fatigue
mitigation processes; and, encourage residents to use fatigue mitigation processes to manage the
potential negative effects of fatigue on patient care and learning. (CPR VI.D.1.a)-c))
Each program must ensure continuity of patient care, consistent with the program’s policies and
procedures, in the event that a resident may be unable to perform their patient care
responsibilities due to excessive fatigue. (CPR VI.D.2.) The program, in partnership with the
UW Health, must ensure adequate sleep facilities and safe transportation options for residents
who may be too fatigued to safely return home. (CPR VI.D.3.)

All residents and faculty are required to complete fatigue mitigation and management education
as part of UW Health’s annual Safety and Infection Control online module, or other GME
Administration-approved training, which will fulfill this requirement. Programs may provide
additional training.
K. Professionalism
Programs, in partnership with UW Health, must educate residents and faculty members
concerning the professional responsibilities of physicians, including their obligation to be
appropriately rested and fit to provide the care required by their patients. (CPR VI.B.1.)
Residents and faculty members must demonstrate an understanding of their personal role in the
assurance of their fitness for work, including management of their time before, during, and after
clinical assignments; accurate reporting of work hours; and, recognition of impairment, including
from illness, fatigue, and substance use, in themselves, their peers, and other members of the
healthcare team. (CPR VI.B.4.c)(1), (2), and VI.B.4.f))
A. Required Program-Specific Policy
Program Directors must develop program-specific policies and procedures consistent with the
institutional and program requirements for work hours and the working environment, including
moonlighting. To that end, programs must:

1. Distribute and implement these policies and procedures to the residents and faculty;
2. Adjust schedules and other processes as necessary to mitigate excessive service
demands and/or fatigue;
3. Provide residents with the opportunity to attend medical, mental health, and dental
care appointments, including those scheduled during their working hours;
4. Ensure continuity of patient care in the event a resident is unable to perform patient
care duties through a system that is without fear of negative consequences to the
resident who is unable to provide the clinical work; and
5. Provide oversight of resident moonlighting activities to ensure residents are meeting
all program and institutional requirements for moonlighting.
B. Professional Responsibility of Resident

If a resident finds him/herself in a situation where s/he is approaching the limits of the
requirements, s/he must notify his/her Program Director immediately. Patterns of problems
experienced by the resident should be reported to the Program Director and/or GME
Administration for correction. In addition, a GME Hotline is available at 608-316-9800 as
another mechanism for reporting work hour problems.

C. Call rooms

If there is not a previously assigned call room available for sleep, a resident may call Bed
Control at 608-263-8775 and ask for a call room in the “resident hotel system.”

D. Safe Ride Home

GME Administration will reimburse a resident for a cab ride home in the case that s/he is too
tired to safely drive themselves home following a duty period. Receipts should be turned in
within 30 days of the ride.
E. Work Hour Compliance Monitoring

All residents are expected to accurately log work hours for each rotation in MedHub. Program
Directors are required to monitor work hours as submitted in MedHub and make schedule or
policy adjustments as necessary. To monitor program compliance, the Graduate Medical
Education Committee (GMEC) reviews the following:

1. Quarterly Med Hub Work Hours reports;
2. ACGME Resident survey data;
3. Data from annual program reviews; and
4. Work hour issues that arise from internal reviews of the program and ACGME site visits.

Additionally, GMEC policy requires action plans and additional monitoring when corrective
action is needed.

F. Request to Moonlight

Residents must submit requests to moonlight, prior to beginning to moonlight, via MedHub.
Requests must be resubmitted each year beginning July 1st. The program director is responsible
for review and approval. Once approved by the program director, GME Administration will
review for approval. Once GME Administration approval has been obtained the resident may
begin moonlighting activities.

G. Request for 80 Hour Exceptions

Eligibility. Both the sponsoring institution and the program must be accredited in good standing
(i.e., without a warning, or a proposed or confirmed adverse action). A program with a
confirmed work hour citation shall not be considered for an exception until after the next
ACGME site visit.

Submittal to GMEC. Eligible programs must submit a written request to the GMEC for up to a
10% exception to the 80-hour limit (or a maximum of 88 hours). It is the program’s
responsibility to present clear evidence that the exception is necessary for educational reasons.
The proposal must include the following documentation:

a. Patient Safety Information. The program must describe how the program and institution
will monitor, evaluate, and ensure patient safety with extended resident work hours.
b. Educational Rationale. The request must be based on a sound educational rationale (not a
service need), which should be 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 should be

considered the exception, not the rule.
c. Moonlighting Policy. Specific information regarding the program’s moonlighting
policies for the periods in question must be included.
d. Call Schedules. Specific information regarding resident call schedules during the times
specified for the exception must be provided.
e. Faculty Monitoring. Evidence of faculty development activities regarding the effects of
resident fatigue and sleep deprivation must be appended.
Submittal to ACGME. Once the GMEC approves the request for an exception, the program
should then submit the request to the respective Review Committee (RC). In preparing a request
for an exception, the program director must follow the clinical and educational work hour
exception policy from the ACGME Manual of Policies and Procedures. Such a request must
also include:
a. Institutional Endorsement. A documented written statement of institutional endorsement
of the proposal signed by the designated institutional official must be appended. In
addition, a copy of the sponsoring institution’s written procedures and criteria for
endorsing requests for an exception to the work hour limits must be submitted.
b. The current accreditation status of the program and of the sponsoring institution should
be provided in the formal request.

Monitoring. Prior to each site visit and review, the Designated Institutional Official and
Graduate Medical Education Committee shall reevaluate both patient safety and the educational
rationale for the exception, and append the findings to the program’s request to the RC for a
continued exception.

A. ACGME Institutional Requirements www.acgme.org
B. ACGME Common Program Requirements www.acgme.org
C. ACGME Manual of Policies and Procedures www.acgme.org
D. ACGME FAQs about the Common Program Requirements www.acgme.org


Sr. Management Sponsor: Susan L. Goelzer, M.D., M.S., Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Administration
Approval Committee: Graduate Medical Education Committee, approved October 18, 2017.


Susan L. Goelzer, M.D., M.S.
Designated Institutional Official/Associate Dean for Graduate Medical Education
Professor of Anesthesiology, Internal Medicine and Population Health Sciences