Applies to: Residents in the WSU Internal Medicine Residency – Everett program.
Date: December 17, 2019
1.0 Policy Statement
It is the Elson S. Floyd College of Medicine Internal Medicine Residency Program, Everett policy to establish and maintain the effective supervision of all Elson S. Floyd College of Medicine sponsored residents in the Internal Medicine Residency Program, Everett.
2.0 Definitions
Accreditation Council for Graduate Medical Education (ACGME)
The ACGME is responsible for the accreditation of post-MD medical training programs within the United States.
Attending Physician
An identifiable, appropriately-credentialed and privileged primary physician (or licensed independent practitioner as approved by the ACGME Resident Review Committee) who is responsible and accountable for that patient’s care. The attending physician is responsible for assuring the quality of care provided and for addressing any problems that occur in the care of patients and thus must be available to provide direct supervision when appropriate for optimal care of the patient and/or as indicated by individual program policy.
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 and patient.
Indirect Supervision
- With direct supervision immediately available – the 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.
Oversight
The supervising physician is available to provide review of procedures/ encounters with feedback provided after care is delivered.
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 resident’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 trainee enrolled in an educational program whose education falls under the purview of the ESFCOM Office of Graduate Medical Education.
3.0 Responsibilities
GMEC through the DIO; Associate Dean for GME; Assistant Regional DIOs.
4.0 Procedures
The Internal Medicine Residency Program recognizes and supports Supervision in the setting of graduate medical education provides safe and effective care to patients; ensures each resident’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth. This policy outlines the requirements to be followed when supervising residents.
The goal of this policy is to promote assurance of safe patient care, and the resident’s maximum development of the skills, knowledge, and attitudes needed to enter the unsupervised practice of medicine. The responsibility for the supervision of residents within the program ultimately resides with the program director at all sites, while in collaboration with the associate program director, and faculty. The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care, consequently, is delegated by the program director and faculty members to each resident.
To promote oversight of resident supervision while providing for graded authority and responsibility, the Everett IM program uses the following classification of supervision [VI.A.2.c)]:
- Direct Supervision: The supervising physician is physically present with the resident and patient.
- Indirect Supervision with Direct Supervision Immediately Available: The supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.
- Indirect 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. Oversight: The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
At all times:
- Each patient must have an identifiable and appropriately-credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable ACGME Review Committee) who is responsible and accountable for the patient’s care. [VI.A.2.a).(1)]
- This information is available to IM residents, faculty members, other members of the health care team, and patients at the start of each rotation based on published schedules for the rotation. [VI.A.2.a).(1).(a)].
- Residents and faculty members inform each patient of their respective roles in that patient’s care when providing direct patient care. [VI.A.2.a).(1).(b)]
- Initially, all PGY-1 residents are supervised either directly or indirectly with direct supervision immediately available until permitted to act with conditional independence.
- Residents on inpatient ward rotation relate to a maximum of four attending physicians, the equivalent of a weekly change, on each rotation.
- The IM Residency establishes schedules which assign qualified faculty physicians, or Senior Residents (when applicable) to supervise at all times and in all settings in which Internal Medicine residents provide any type of patient care. The type of supervision to be provided is delineated in the curriculum’s rotation description and/or the graduate levels of responsibility.
- The minimum amount/type 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.
- All residents, regardless of year of training, must communicate with the appropriate supervising faculty member any changes in condition of the patient highlighted in the rotation guidelines.
- In every level of supervision, the supervising faculty member must review progress notes, sign procedural and operative notes, and discharge summaries.
- Faculty members must be continuously present to provide supervision in ambulatory settings, and be actively involved in the provision of care, as assigned.
- Residents on Internal Medicine inpatient rotations are never supervised by a resident from another specialty unless it is procedural assistance.
Contacting Faculty Regarding “Must Call” Patient Care Policy [VI.A.2.e)]
There are situations when it is required that residents be in contact with faculty regarding patient care:
- Admissions and discharges (especially unexpected discharges)
- Advance care planning, change in code status
- Inpatient transfers to a different level of care
- Consultations with other physicians
- Major changes in a patient’s condition
- Planned invasive procedure
- Uncertainty regarding the diagnosis
- Critical care time spent (>15 minutes patient care time of admitted patient)
The following criteria are adapted from ICU transfer guidelines. If a patient has one of the following conditions, the resident must contact the attending physician.
- Hemodynamic change that is not responsive to treatment, (e.g. fluid challenge) for example a pulse <50 or >130 or SBP <88
- Urine output <20cc an 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
Attending physicians are available for guidance 24 hours a day. The resident should call with any Discomfort, uncertainty, or disagreement regarding a patient’s status or the need for guidance with management issues of both new and established patients.
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 Elson S. Floyd 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 Elson S. Floyd 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
Elson S. Floyd College of Medicine GME Supervision and Accountability Policy.
Responsible Office: Designated Institutional Official; GME Office; Program Director
Policy Contact: Program Director, Program Administrator, GME Office
Supersedes: N/A