COTTAGE HEALTH SYSTEM POLICY

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SUBJECT:

Internal Medicine RESIDENT PHYSICIAN SUPERVISION POLICY

 

DEPT: MEDICAL EDUCATION
POLICY #: 8240.07

 

GOAL

To define responsibility for supervision of Internal Medicine residents in order to a) provide safe and effective medical care to our patients, and b) provide a superior and safe training program for our residents.

 

This supervision will be an extension of the SBCH policy on "Resident Supervision", as formulated by the Graduate Medical Education Committee (GMEC).  The stated goals of that SBCH policy are as follows.

 

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 activites 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.

 

POLICY

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.

 

I. 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

i.  The supervising physician is physically present with the resident and patient.

 

b. Indirect Supervision

i.  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.
ii.  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.

 

c. Oversight

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.

a.  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.
b.  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.
c.  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.

 

II.  Resident Responsibilities

  • The resident must inform every patient under his/her care what his/her training status is and the name of the attending physician who is his/her supervisor.  (Ex: "Hello. I am Dr. Smith.  I am a second year internal medicine resident.   Dr. Jones is my attending physician and will be supervising all the care that I provide to you.")
  • The resident must seek the appropriate supervision from his/her supervisor for his/her level of training.
  • The resident must immediately notify his/her supervising physician if, for any reason, he/she is unable to carry out his/her clinical responsibilities. This includes fatigue, stress, and lack of experience.

 

III. Communication to Supervising Physician by PGY1 (to supervising resident or attending physician).

The PGY1 should contact the supervising resident immediately in the following circumstances:

1.

  Medical Services floor patient:  
    If a patient has to be transferred to a higher level of care (ICU)
    Procedures are necessary
    Significant change in status (to include major change in condition, emergency surgery, respiratory distress, AMA, code, new comfort measures, unexpected death)
   

Patients who are newly made DNR/DNI

    Need for urgent/emergent consultation
    Significant unresolved interpersonal communication issues with patients and/or families
    New patient expected to expire before being seen by attending physician
     

Uncertainty about cross-coverage issues or about any other patient care decision, for which thresident would like supervision

2.   ICU Patient
    All new admissions (note ICU attending must be contacted by senior resident for all proposed transfers from outside facility to ICU) before transfer is accepted)
   

All patients who require intubation and mechanical ventilation

    All patients started on cardiac/critical infusions (levophed, dobutamine, etc.)
    All patients with an acute change in their neurological status
    All patients undergoing withdrawal of life support
   

All patients who are newly made DNR/DNI

    All patients who require new consultative support
    All unanticipated deaths
       

IV. Communication to Attending physician by supervising resident.
   

a.  The supervising resident should contact the Attending physician as soon as possible in the following circumstances.

1.

  Medical Services floor patient:  
    Any clinical situation in which the supervising resident wishes urgent assistance.
    Transfer of a patient from medical ward to the ICU due to medical instability
    Unexpected death
2.     ICU Patient
    All new admissions (note ICU attending must be contacted by senior resident for all proposed transfers from outside facility to ICU) before transfer is accepted)
    All patients who require intubation and mechanical ventilation
    All patients newly started on cardiac/critical infusions (levophed, dobutamine, etc.)
    All patients with an acute or unanticipated significant change in their status
    All patients with a new decision to withdraw life support
    All patients who are newly made DNR/DNI

b.  An attending physician should always be contacted if the resident has unanswered questions or ongoing concerns about a patient?s status or condition.
c. The attending physician should always be contacted prior to the Resident discharging from the Emergency Department a patient whom the Emergency Department M.D. feels should be admitted to the hospital.

 

V.  Attending Physician Availability

  • An identified on-call attending physician will be available by pager or cell phone 24/7/365, and will be able to return if not already in hospital to directly supervise the resident within 60 minutes.

VI. Inadequate Supervision

  • If a PGY 1 feels he/she is receiving inadequate supervision by a senior resident, he/she should notify chief resident, the Attending, or the Program Director immediately.
  • If a Senior Resident feels he/she is receiving inadequate supervision by an Attending, he/she should notify the Program Director or Vice President of Medical Affairs immediately.

VII. Failure to Seek Appropriate Supervision

  • If the PGY 1 fails to seek appropriate supervision, the senior resident will notify the attending and Program Director.
  • If the senior resident fails to seek appropriate supervision, the attending will notify the Program Director.
  • This supervision policy is the key to balancing the right of our patients to receive safe and effective care with one?s educational needs as a physician in training.  Failure to follow the supervision policy is therefore a significant patient safety issue and will be dealt with accordingly.  Supervision Policy violations will be dealt with in a graduated fashion.

VIII. Procedures (see separate policy on Certification of Competence in Procedures)

  • Residents may perform specified procedures independently once they have been certified as competent in that procedure by the Program Director.\
  • A list of all procedures for which resident has been certified as competent is available on the employee portal.
  • A resident must be supervised by a certified competent senior resident or Attending while performing any procedure for which the performing resident has not been already certified as competent.  The exception would be in an emergency situation for which delay would jeopardize the patient?s status.

IX.  Outpatient Care

  • All residents will be directly supervised by designated attending physicians at all clinics of the Santa Barbara County Public Health Department.
  • All residents will be directly supervised by the designated voluntary Attending mentor on elective rotations.

X.  Emergency Department

  • Any resident on an Emergency Medicine rotation will be directly supervised  by the Emergency Medicine Attending staff.

 

5/12

 


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COTTAGE HEALTH SYSTEM POLICY


RECOMMENDED BY: A. Gersoff, MD DATE: 5/11

ORIGINAL POLICY EFFECTIVE DATE: 9/99

APPROVED BY: E. Wroblewski, MD DATE: 5/11

DATE REVISED: 5/07, 5/11, 7/11
DATE REVIEWED: 3/00, 4/01, 7/11