28.1.04 - Duty Hours Policy

Undergraduate Medical Education: School of Medicine

Last Updated: 03/30/2016

Original policy date: 03/30/2016

Applies to: Faculty, Staff, Students



This policy is necessary to comply with Liaison Committee on Medical Education (LCME) standard 8.8, which reads “the medical school faculty committee responsible for the medical curriculum and the program’s administration and leadership ensure the development and implementation of effective policies and procedures regarding the amount of time medical students spend in required activities, including the total number of hours medical students are required to spend in clinical and educational activities during clerkships.”



Compliance of this policy is mandatory for all Baylor College of Medicine (BCM) faculty members who teach, facilitate, and/or precept medical students in the clinical setting.



Duty hours are defined as time spent in all clinical and academic activities related to the program; e.g., patient care (inpatient and outpatient), administrative duties relative to patient care, the provision of transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences.  Duty hours do not include reading and/or preparation time spent away from duty site.



Duty hours, including all in-house call activities, must be limited to an average of 80 hours per week over a four-week period. Duty periods may be scheduled to a maximum of 24 hours of continuous duty in the hospital. An additional four hours may be spent to ensure appropriate, effective and safe transition of care.  Minimum time off between scheduled duties is 10 hours. Students must also receive a minimum of either 24 hours off per seven-day work period, or four days off per 28-day work period. 



Clinical Course Directors in the BCM School of Medicine (SOM) are responsible for 1) ensuring their courses comply with this policy, 2) providing timely notice of any emerging issues or barriers that may impede full compliance (e.g. faculty non-compliance, course organization) to the Department Chair and the Clerkship and Sub-internship Subcommittees; and 3) immediate reporting of any violation of this policy to the Department Chair and the Curriculum Committee.
Department Chairs are ultimately responsible for supervising associated Course Director(s) to ensure departmental compliance with this policy.



·         Questions regarding duty hour compliance must be included in all clinical end-of-course evaluations. Data is compiled and reviewed by the Office of Curriculum Accreditation on a term-by-term basis.
·         On a term basis, compliance results for all clerkships and subinternships are summarized by the Office of Curriculum Accreditation and Special Projects Coordinator. Results are distributed to the Curriculum Committee Chair, Clerkship and Subinternship Subcommittees of the Curriculum Committee, and Clerkship and Subinternship Directors.
·         The Clerkship and Subinternship Subcommittees of the Curriculum Committee review the data, as well as any reported barriers to compliance and duty hour violations, and then present a report to the full Curriculum Committee. 
·         The full Curriculum Committee will determine if a remediation plan is warranted, and if so, the Committee will approve a remediation plan and/or a list of specific issues or actions that clinical courses or departments must address to achieve compliance with this policy. 
·         Course directors and Department Chairs are expected to conduct a root cause analysis to remove any identified issues or barriers to compliance, as needed.



Actions may be taken by the Dean, or by Department Chairs with the approval of the Dean, against Course Directors and/or other faculty members who repeatedly fail to maintain duty hours standards described in this policy or who are otherwise noncompliant, e.g. remediation, reassignment of teaching responsibilities, removal/replacement of Course Director.
In the event of departmental noncompliance, it is at the discretion of the Dean to determine and undertake appropriate and necessary action to bring the department into compliance with this policy, including remediation and/or supervision of a given Department Chair’s scheduling of duty hours.  









LCME Standard 8.8