To define responsibility for supervision of Residents in various venues.
In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient's care. This information should be available to residents, faculty members, and patients. Residents and faculty members should inform patients of their respective roles in each patient's care.
The program must demonstrate that the appropriate level of supervision is in place for all residents who care for patients. Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced resident or fellow. Other portions of care provided by the resident can be adequately supervised by the immediate availability of the supervising faculty member or resident physician, either in the institution, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of resident-delivered care with feedback as to the appropriateness of that care.
Residents involved in patient care are responsible ultimately to the attending physician, with intermediate supervision potentially under the auspices of a more senior resident in the same specialty.
Levels of Supervision
To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision:
a. Direct Supervision
||The supervising physician is physically present with the resident and patient.
b. Indirect Supervision
||with direct supervision immediately available: Tthe supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide direct supervision.
||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.
The supervising physician is available to provide review of procedures / encounters with feedback provided after care is delivered.
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.
||The program director must evaluate each resident's abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria.
||Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents.
||Senior residents or fellows should 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.
Programs must 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.
||Each resident must know the limits of his / her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence.
||In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Each Review Committee will describe the achieved competencies under which PGY-1 residents progress to be supervised indirectly, with direct supervision available.]
Faculty supervision assignments should 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.
Each residency program shall submit a program-specific resident supervision policy to the GMEC. The GMEC will approve each policy based on current ACGME and RRC definitions and expectations. The following are general guidelines, with more specific detail to be provided by each residency program:
Outpatient Settings: The resident shall be supervised directly by a designated attending physician, whether at the Public Health Department or in a private setting.
Inpatient Settings: The most senior resident on a team is responsible directly to the attending physician of record, and shall supervise directly the medical care offered by more junior residents, who may in turn supervise the care offered by residents and medical students more junior to them.
Any of the residents involved in patient care shall have the ability to access directly the responsible attending physician.
If a nurse or other healthcare worker (HCW) has a question or concern regarding a resident's plan / orders, that nurse or HCW should contact the involved resident directly. If the ensuing discussion fails to resolve the question / concern, the nurse or HCW may contact the next most senior resident involved, and so on up the chain of command, to the attending physician.