Supervision

SUPERVISION OF RESIDENTS AND FELLOWS

 PURPOSE

The ACGME Institutional Requirements require that the GMEC ensure that GME Programs provide appropriate supervision for all residents and fellows, as well as a duty hours schedule and a work environment which is consistent with proper patient care, the educational needs of residents and fellows, and the applicable program requirements.

 Each program is required to develop a written program-specific supervision policy consistent with the principles set forth in this institutional policy and ACGME Common and Specialty/subspecialty requirements.

 POLICY

The GMEC is responsible for establishing and monitoring policies and procedures with respect to the institution’s residency and fellowship training programs. Residents and fellows must be appropriately supervised at all times and in all settings in which GME occurs. This includes both inpatient and outpatient settings, as well as any rotation away from the sponsoring institution. In these clinical learning environments, each patient must have an identifiable, appropriately-credentialed, and privileged attending physician who is ultimately responsible for that patient’s care. This information should be available to other medical staff members, residents and fellows, other health care providers, and patients. Residents/fellows, medical staff members, and other health care providers should inform patients of their respective roles in each patient’s care.

 DESCRIPTION

To ensure oversight of resident supervision and graded authority and responsibility, the each GME program will use the following classification of supervision:

 1. Supervising Physician: A physician, either medical staff member or more senior resident/fellow, designated by the program director as the supervisor of a junior resident/fellow. Such designation must be based on the demonstrated medical and supervisory capabilities of the physician.

 2. Licensed Independent Practitioner (LIP): Physician extenders (e.g. physician assistants, nurse practitioners or advanced practice nurses) with particular expertise in certain diagnostic or therapeutic procedures may provide supervision of residents/fellows, if so designated by the program director.

 3. Direct Supervision: The supervising physician is physically present with the resident/fellow and patient.

 4. Indirect Supervision:

a. With direct supervision immediately available – the supervising physician is physically present within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.

b. With direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.

 5. Oversight: The supervising physician/provider is available to provide review of procedures/encounters with feedback provided after care is delivered.

 PROCEDURES

1. Progressive Authority and Responsibility: The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members.

A. The program director will evaluate each resident’s abilities based on specific criteria.  When available, evaluation should be guided by specific national standards-based criteria.

B. Faculty members functioning as supervising physicians will delegate portions of care to residents, based on the needs of the patient and the skills of the residents.

C. Senior residents or fellows will serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow.

 2. The program will demonstrate that the appropriate level of supervision is in place for all residents who care for patients by putting each Program Director in charge of overseeing, ensuring, and documenting adequate supervision of residents at all times.

 3. Programs will set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members, such as the transfer of a patient to an intensive care unit, or end-of-life decisions.

A. The residents will know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act within conditional independence.

 4. PGY-1 residents must always be supervised either directly or indirectly with direct supervision immediately available.

 5. Faculty supervision assignments will be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility.

 6. Each Program Director must delineate patient care circumstances and procedures that require direct, indirect, or oversight supervision of all residents/fellows in the program. This should be specific to each resident’s/fellow’s competency and level of training. In some cases, institutional policy will define the minimum experience and competency required before residents/fellows may perform certain procedures without direct supervision.

 7. Each Program Director will complete a listing of resident/fellow clinical activities that are permitted by level of training, the required level of supervision for each activity, and any requirements for performing an activity without direct supervision. These descriptions must be provided to the residents/fellows and supervising physicians and also be readily available to other health care providers as needed.

 8. Direct Supervision must be documented in the health record by supervising physician notes. Indirect Supervision may be documented in the health record. An audit of medical records in accordance with the hospital’s Compliance Plan will monitor documentation of supervision. Audit results will be presented to the Designated Institutional Officer (DIO) and the program directors. The GMEC will oversee this reporting.

 9. Emergency procedures may require immediate action by a resident/fellow while awaiting supervising physician arrival.

 10. Residents/fellows must have rapid, reliable systems for communication with supervising physicians.

 11. On-call and clinical assignment schedules, including contact information, must be available at all clinical service locations so that house staff as well as other health care providers can easily identify the physician(s) responsible for providing supervision.

 12. Supervising physicians, residents, and fellows will adhere to policies created to recognize signs of fatigue and will follow guidelines in order to prevent and counteract its potential negative effects.

 13. The Program will have mechanisms by which residents/fellows can report inadequate supervision in a protected manner that is free from reprisal.

 MONITORING OF SUPERVISION

1. The Director of the GME Program is responsible for ensuring that the institution fulfills all responsibilities identified within this section.

 2. Along with the DIO, each Program Director is responsible for monitoring resident supervision, identifying problems, and devising plans of action for their remedy.

 3. At a minimum, the monitoring process will include:

A. A review of compliance with inpatient and outpatient documentation requirements, as part of medical record reviews;

B. A review of all incidents and risk events with complications to ensure that the appropriate level of supervision occurred;

C. A review of all accrediting and certifying bodies’ concerns and follow-up actions;

D. A review of resident evaluations of their faculty and rotations;

E. An analysis of events where violations of graduated levels of responsibility may have occurred;

F. A review of all tort claims involving residents, to determine if there was an appropriate level of supervision.

G. Reviews pertaining to monitoring of resident supervision will be communicated, at a minimum, on a yearly basis, to the Board of PSPC.