Clinical Experience & Education (Duty Hours) Policy


The University at Buffalo (“UB”) and its affiliated hospitals support a work environment that is safe and conducive to learning. Compliance with the ACGME requirements and New York State Department of Health regulations on duty hours contributes to such an environment.

In the event of a conflict in requirements/regulations, residents/fellows and faculty in UB- sponsored training programs must adhere to the more stringent of the two. The clinical environment must be conducive to resident learning and support acquisition of knowledge, skills, and attitudes identified by the ACGME.

Requirements and Regulations

Key features of the clinical experience and education (duty hours) requirements and regulations, which apply to UB-sponsored, ACGME-accredited residency programs, are included in the attached: “NYS-ACGME Post-Graduate Trainee Work-Hour Regulations Comparison Guide,” prepared 4/25/2017 by the New York State Department of Health.

Resident, faculty, program director, GMEC, and hospital/health system responsibilities are listed in the 7/1/2017 ACGME Common Program Requirements (CPR) pertaining to Clinical Experience and Education (Duty Hours). Details on implementing these policies at UB follow below.

Residents and fellows are responsible for:

  • Reporting duty hours or other learning environment concerns by notifying their program director, chief resident, and/or the Senior Associate Dean for Graduate Medical Education; or by submitting concerns anonymously via the “red phone” link on the Graduate Medical Education website.
  • Notifying their supervising faculty physician immediately if circumstances (e.g. patient emergency) may lead to violation of duty hours regulations.
  • Timely, accurate and complete logging duty hours via the web-based tracking system in accordance with institutional and program guidelines.
  • Providing complete information regarding their duty hours and supervision to representatives of the sponsoring institution, ACGME, affiliated hospital administration, and/or Department of Health (IPRO), when requested.

Program Directors must ensure compliance with requirements and regulations by:

  • Writing, implementing and maintaining program-specific policies and procedures consistent with:
    • Institutional policies and procedures
    • ACGME Institutional, Common, and Program-Specific requirements
    • New York State Department of Health (NY DOH) regulations
  • At minimum, these must include procedures for regularly monitoring:
    • Duty Hours
    • The safety and quality of the learning environment
    • Contingency plans to support patient care during unexpected resident shortages, resident fatigue, and/or excessive clinical demands
  • Educating residents and faculty members about:
    • Professional responsibilities to appear for duty appropriately rested and fit to provide services required by patients
    • Duty hour reporting requirements and interpretation of survey questions
  • Monitoring resident duty hours in accordance with ACGME requirements, NYS DOH regulations, and UB GMEC/Program Quality Review Subcommittee (PQRS) determinations. This must include, at minimum:
    • Ensuring that residents log duty hours per PQRS determinations
    • Monitoring resident duty hours logged in the Electronic Residency Management System (e.g. E*Value, MedHub) per PQRS determinations
    • Providing timely, accurate, and complete information to PQRS, ACGME and IPRO as requested

The GMEC will oversee compliance with requirements and regulations by:

  • Reviewing data from ACGME annual surveys
  • Reviewing internal data on a schedule appropriate to the compliance history of the program and as determined by the GMEC/PQRS and/or Designated Institutional Official. This includes but is not limited to:
    • Information collected via the Electronic Residency Management System (e.g. E*Value, MedHub)
    • Anonymous “red phone” reports
    • Program Quality Reviews

Substantial compliance is defined as, at minimum, 70% logging compliance and NO VIOLATIONS for a consecutive, three-month period. Compliant programs may request semi-annual duty hour logging. PQRS will review these requests in conjunction with relevant requirements (including program-specific requirements) and regulations.

  • Reporting persistent non-compliance to the Dean, Jacobs School of Medicine and Biomedical Sciences and VP for Health Affairs; Department Chairs; and hospital leadership (e.g. Hospital Official for GME and CEO or equivalent)
  • Determining appropriate sanctions for persistent non-compliance, which may include: overseeing the scheduling process, prohibiting training at specified locations or units, restricting supervision by selected physicians, or program closure.

The GMEC will monitor learning environment using:

  • ACGME and internal surveys
  • Annual Program Reviews
  • Special Reviews
  • Reports from Residents

UB-affiliated hospitals are responsible for:

  • Providing summary information of their patient safety reports to UB-sponsored, ACGME-accredited programs and the GMEC
  • Providing residents/fellows and faculty members with data on quality metrics and benchmarks related to their patient populations

Established:  1994
GMEC Approved Date:  February 20, 2018