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  1. Each program director must sign a statement attesting to compliance with the requirements at all sites.
  2. Each program will develop their own written AnchorOLE_LINK1OLE_LINK1 AnchorOLE_LINK2OLE_LINK2 clinical and educational work hour policy in compliance with the ACGME and LSUHSC Institutional policy. This policy will be distributed to all trainees and faculty with a copy provided to the GME Office. The policy must specifically address how compliance will be monitored and what actions will be taken to remedy problems. Yearly changes or revisions to policies must be forwarded to the GME Office.
  3. Programs must monitor House Officers for fatigue. The Sponsoring Institution provides resources to educate faculty and House Officers about sleep deprivation and fatigue.
  4. The Sponsoring Institution will ask each participating site to advise (where legally permissible) it of incidents or trends that suggest fatigue is an issue.
  5. If the Program has instituted a method to monitor for individual House Officer clinical and educational work hour compliance (e.g. work hour logs) it will regularly share this data with the Sponsoring Institution.
  6. In addition to other monitoring, the Sponsoring Institution encourages programs to add questions regarding clinical and educational work requirements to their monthly rotation evaluations.
  7. The Sponsoring Institution will advise House Officers that the Ombudsman Ombud is available to field anonymous questions or complaints about clinical and educational work hours
  8. The House Officer Agreement of Appointment/Contract includes a reference to clinical and educational work hours policy and an agreement to participate in institutional monitoring of clinical and educational work hours
  9. Special Focused Reviews may include detailed review of clinical and educational work hours
  10. An annual anonymous web-based questionnaire will be administered to House Officers regarding clinical and educational work hours by the GME Office
  11. The GME Office will randomly audit programs for clinical and educational work hour compliance
  12. Program-specific data will be presented annually in the PEC meeting minutes submitted to the GME Office
  13. Violations of clinical and educational work hour requirements by participating sites may result in removal of House Officers from that site
  14. Programs with constant violations will be regularly monitored by GMEC and may be subject to closureSpecial monitoring programs will be implemented for programs cited by the ACGME for clinical and educational work hour violations
  15. Moonlighting must be approved in writing and strictly monitored to assure House Officer fatigue does not become a problem
  16. House Officers may anonymously report violations to the Clinical and Educational Work Hours Hotline at (504) 599-1161.