Applies to: Residents, Faculty, and Staff in the WSU Family Medicine Residency–Pullman residency program.
Date: November 17, 2020
1.0 Policy Statement
It is the WSU College of Medicine policy to establish and maintain the effective supervision of all WSU-sponsored residents and fellows in training.
2.0 Definitions
Accreditation Council for Graduate Medical Education (ACGME)
Accredits Sponsoring Institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of importance in graduate medical education.
Attending Physician
The single identifiable physician ultimately responsible and accountable for an individual patient’s care, who may or may not be responsible for supervising Trainees.
Designated Institutional Official (DIO)
The individual in a sponsoring institution who has the authority and responsibility for oversight and responsibility of all of the ACGME-accredited programs.
Direct Supervision:
- The supervising physician is physically present with the Trainee during the key portions of the patient interaction; or,
- PGY1 residents must initially be supervised directly, only as described above. (Programs define, based on the appropriate ACGME Residency Review Committee’s guidelines, the competencies that PGY1 residents must achieve in order to progress to be supervised indirectly with direct supervision available.)
- The supervising physician and/or patient is not physically present with the Trainee and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology (the specific ACGME Review Committee must further specify if this is permitted).
Faculty
The group of individuals (both physician and non-physician) assigned to teach and supervise residents/fellows.
Indirect Supervision
The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.
Oversight
The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
Post-Graduate Year (PGY)
The denotation of a post-graduate trainee’s progress in residency or fellowship training, used to stratify responsibilities in most programs. The PGY does not necessarily correspond to the trainee’s year in an individual program. For example, a fellow who has completed a pediatric residency program and is in the first year of a pediatric endocrinology fellowship program is a pediatric endocrinology 1 level and a PGY4.
Program Director
The appointed faculty member with authority and accountability for the overall program, including compliance with all applicable program requirements.
Progressive Responsibility
Graded and progressive responsibility provided to a Trainee according to the individual Trainee’s clinical experience, judgment, knowledge, and technical skill.
Supervision
In the setting of graduate medical education provides safe and effective care to patients; ensures each Trainee’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth.
Trainee
A physician in training at an ACGME-accredited graduate medical education program. The term includes Interns, Residents, and Fellows or other trainees enrolled in an educational program whose education falls under the purview of the Elson S. Floyd College of Medicine Office of Graduate Medical Education.
3.0 Responsibilities
Program Director
4.0 Procedures
Family Medicine Residency Program–Pullman will oversee the supervision of Trainees and provide mechanisms by which Trainees can report inadequate supervision and accountability in a protected manner that is free from reprisal (IR III.B.4.). The program will define, widely communicate, and monitor a structured chain of responsibility and accountability as it relates to the supervision of all patient care [CPR VI.A.2.a]. This supervision policy is consistent with the ACGME Institutional, Common, and specialty/subspecialty Program Requirements and College of Medicine GME policies.
Attending Physician
At all times:
- Each patient must have an attending physician (or licensed independent practitioner as specified by the applicable ACGME Review Committee) who is responsible and accountable for the patient’s care. [CPR VI.A.2.a.(1)]
- This information must be available to Trainees; faculty members, other members of the healthcare team, and patients. [CPR VI.A.2.a(1).(a)]
- Residents and faculty members must inform each patient of their respective roles in that patient’s care when providing direct patient care. [CPR VI.2.a.(a).(b)]
Levels of Supervision
Supervision may be exercised through a variety of methods. 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 appropriate availability of the supervising faculty member, fellow, or senior resident physician, either on site or by means of telecommunication technology. Some activities require the physical presence of the supervising faculty member. In some circumstances, supervision may include post-hoc review of resident-delivered care with feedback. [CPR VI.A.2.b)]
The program must demonstrate that the appropriate level of supervision in place for all Trainees is based on each Trainee’s level of training and ability, as well as patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation. [CPR VI.A.2.b).(1)]. Each ACGME Review Committee may specify which activities require different levels of supervision. The program must define when physical presence of a supervising physician is required.
To promote oversight of resident supervision while providing for graded authority and responsibility, the program must use the following classification of supervision [CPR VI.A.2.c)]:
Direct Supervision
- The supervising physician is physically present with the Trainee during the key portions of the patient interaction; or
- PGY1 residents must initially be supervised directly, only as described above. (Each program must define, based on the appropriate ACGME Residency Review Committee’s guidelines, the competencies that PGY1 residents must achieve in order to progress to be supervised indirectly with direct supervision available.
- The supervising physician and/or patient is not physically present with the Trainee and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.
Indirect Supervision
The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.
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 Trainee must be assigned by the Program Director and faculty members. [CPR VI.A.2.d)]
- The program director must evaluate each resident’s abilities based on specific criteria, guided by the Milestones.
- Faculty members functioning as supervising physicians must delegate portions of care to residents based on the needs of the patient and the skills of each resident.
- Senior residents or fellows should serve in a supervisory role to 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.
Each program must set guidelines for circumstances and events in which Residents must communicate with appropriate supervising Faculty members, such as after-hours clinic call, the transfer of a patient to an intensive care unit, taking a patient to surgery, or end-of-life decisions. [CPR VI.A.2.e)]
- Each resident must know the limits of his/her/their scope of authority and the circumstances under which he/she/they is permitted to act with conditional independence.
- Initially, PGY1 residents are supervised directly. (Programs define, based on the appropriate Residency Review Committee’s guidelines, the competencies that PGY1 residents must achieve in order to progress to be supervised indirectly.)
The Program Director (or his/her/their designee) must structure faculty supervision assignments for each rotation or clinical experience (inpatient or outpatient) to be of sufficient duration to assess the knowledge and skills of each resident and to delegate to the resident the appropriate level of patient care authority and responsibility. [CPR VI.A.2.f)]
Residents at the Family Medicine Residency Program–Pullman will have the following progressive levels of supervision:
- Initially all PGY1 trainees are supervised directly until they are permitted to act with conditional independence.
- The program establishes a schedule which assigns qualified faculty physicians or senior residents (when applicable) to supervise at all times and in all settings in which family medicine residents provide any type of patient care. The type of supervision to be provided is delineated in the curriculum’s rotation description.
- The minimum amount of supervision required in each situation is determined by the definition of the type of supervision specified but is tailored specifically to the demonstrated skills, knowledge, and ability of the individual resident. In all cases, the faculty member functioning as a supervising physician should delegate portions of the patient’s care to the resident, based on the needs of the patient and the skills of the resident as well as the privileges of the attending physician.
- Senior residents and fellows serve in a direct or indirect supervisory role of junior residents in recognition of their progress toward independence.
- Faculty members must be continuously present to provide supervision in ambulatory settings and must be actively involved in the provision of care as assigned.
Residents must inform the attending physician of the following:
- Potential admissions from the ED must be discussed with the attending prior to acceptance
- Admissions and unplanned discharges/patients who leave AMA
- Inpatient transfers to a different level of care
- Consultation with other physicians
- Major changes in a patient’s condition
- Planned invasive procedure
- Uncertainty regarding diagnosis
- More than 15 minutes of critical care time
The resident must contact the attending physician if the patient has sudden or unexpected deterioration, to include:
- Hemodynamic change that is not responsive to treatment
- Urine output <20cc and hour unresponsive to therapy (if unexpected)
- Acidosis with pH <7.2
- Complicated MI, CHF, or arrhythmia
- Multisystem organ failure
- Severe GI bleed
- Sustained change in level of consciousness
- Respiratory distress
- Hyperkalemia refractory to treatment
- Unexpected death
- Low-risk deliveries, once a primiparous patient is complete or a multiparous woman is 6 to 8 cm, dependent on the specific circumstances of each case
- Complicated obstetric patients, as appropriate to the circumstances of each case. This supervision may be provided by either the family medicine attending physician or by the consulting obstetrician in the event that Family Medicine has transferred care to obstetrics.
Supervision of Invasive Procedures
Any procedure performed by a resident must be directly supervised unless the resident has been approved to perform that procedure independently. When a resident requires supervision, this may be provided by a qualified member of the medical staff or by a resident who is authorized to perform the procedure independently. In all cases, the attending physician is ultimately responsible for the provision of care by residents. When there is any doubt about the need for supervision, the attending should be contacted.
The following procedures may be performed with the indicated level of supervision:
Direct supervision required by a qualified member of the medical staff:
- Any operating room procedure
- Vaginal delivery, including repair of vaginal lacerations or episiotomy, repair of cervical laceration, uterine exploration
- Colposcopy and cervical cryotherapy
- D&C or D&E, uterine
- Exercise treadmill test
- Flexible or rigid sigmoidoscopy
- Sedation for procedures
- Vasectomy
- All other invasive procedures not listed
- All procedures done in the hospital require direct supervision for billing purposes
Direct supervision required by a qualified member of the medical staff until competency demonstrated, then indirect supervision:
A resident may be released for independent performance of a procedure that is within the usual scope of practice of family physicians in that institution, when the resident has been supervised for a number of that procedure sufficient for faculty to assure the resident’s competency in knowledge and skill for independent practice relating to that procedure.
| Procedure | Number of procedures completed with competency for independent performance (or training equivalent) |
| Abdominal paracentesis | 3 procedures |
| Application of casts or splints | 3 procedures |
| Arterial catheterization | 3 procedures |
| Arthrocentesis | 3 procedures |
| Central line placement: internal jugular | 3 procedures |
| Central line placement: subclavian | 3 procedures |
| Lumbar puncture | 3 procedures |
| I&D of abscess | 1 procedure |
| IUD placement | 3 procedures |
| Nasogastric tube placement | 1 procedure |
| Neonatal circumcision | 6 procedures |
| Obstetrical procedures: placement of Cervidil, IUPC, fetal scalp electrode, limited OB ultrasound | Completion of R1 OB rotation |
| Skin biopsy | 3 procedures |
| Skin lesion excision | 3 procedures |
| Thoracentesis | 3 procedures |
| Toenail removal | 3 procedures |
| Urethral catheter | 1 procedure |
Oversight required by a qualified member of the medical staff:
- Dressing changes, suture placement and removal, central venous catheter removal, cryotherapy of small skin lesions (<5mm), anoscopy, breast exam, pelvic exam, pap smear, and endocervical cultures.
Reporting Inadequate Supervision
Trainees can report inadequate supervision and accountability that is free from reprisal using several mechanisms.
- Reports of inadequate supervision and accountability can be submitted directly to faculty, the program director, any GMEC member, or to the DIO.
- Reports of inadequate supervision and accountability can be submitted anonymously through the GME Hotline, monitored by the GME Office.
- An College of Medicine web submission form can be utilized by Trainees for all anonymous reporting related to supervision or other program or institutional compliance issues or concerns.
- Reports can also be submitted through the College of Medicine GME Resident Management System.
- Trainees can utilize any one of the multiple evaluations process in place including the Institutional and Program Evaluations as well as the annual ACGME survey.
5.0 Related Policies
GME Supervision and Accountability Policy
6.0 Revision History
GMEC Approval: February 16, 2021
Revision/Review Date(s):
Responsible Office: GME Office, Program Director
Policy Contact: Program Director, Program Administrator
Supersedes: N/A