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Supervision and Autonomy in GME : “Watching closely at
a distance”
SHC, Department of GME Program Directors’ Education Lunch MeetingSept . 9, 2010
“Supervision is more important than [duty] hours” Dr. Bertrand Bell, 2009
Discussion Points
What is supervision? ACGME old and new regulations for
faculty supervision How do we measure supervision? What do we know about resident
supervision from the literature? Legal standards for resident
supervision
SUPERVISION2003 2011 The program must
ensure that qualified faculty provide appropriate supervision of residents in patient care activities.
Residents and attending should inform patients of their role in the patient’s care
Faculty functioning as supervising physicians should delegate portions of that care to resident physicians
Senior residents or fellows should serve in a supervisory role of junior residents
The privilege of progressive responsibility in patient care delegated to each resident must be assigned by the program director and faculty
The resident is responsible for knowing the limits of his/her scope of authority
Programs must set guidelines for circumstances and events where residents must communicate with appropriate supervising physicians
Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of the resident and delegate the appropriate level of patient care authority and responsibility.
In particular, during the PGY 1 year, residents must have supervision level 1 or 2a (see below)
Levels of Supervision. In the development and description of systems to oversee resident supervision and graded authority and responsibility, each program must use the following classification of supervision.
Direct Supervision —The supervising physician is physically present with the resident and patient
Indirect Supervision: Direct supervision immediately available – The
supervising physician is physically within the confines of the site of patient care, and immediately available to provide Direct Supervision
Direct supervision available – The supervising physician is not physically present within the confines of the site of patient care, is immediately available via phone, 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.
But we always supervise… or at least we think that we do!
The changes in supervision are not only operational… they are also changes in accountability for supervision policies, measurement and documentation of supervision.
2010 House Staff Survey
Supervision
to watch over so as to maintain order, etc
“the provision of guidance and feedback on matters of personal ,professional, and educational development in the context of providing safe and appropriate care” (Butters J, “Legal Standards of Conduct for Students and Residents : Implications fir Health Professions Educators”, ACAD Med 71, 583)
Aims of Supervision
To promote professional development
To ensure patient safety
Implications of Supervision
Patient Safety Preventing averse outcomes Limiting institutional liability
Medical Education Train competent physicians
Re-imbursement HCFA/CMA guidelines
SUPERVISION – 2011 (1 of 4) Residents and attendings should inform
patients of their role in the patient’s care Faculty functioning as supervising physicians
should delegate portions of that care to resident physicians
Senior residents or fellows should serve in a supervisory role of junior residents
SUPERVISION – 2011 (2 of 4)
The privilege of progressive responsibility in patient care delegated to each resident must be assigned by the program director and faculty (job descriptions on MSO)
The resident is responsible for knowing the limits of his/her scope of authority (job descriptions on MSO)
Job descriptionfs on MSO-NET are decigned to eet Joint commission Standards (not ACGME)
Our suggestion is to build on these aviallbe job descritions
JOB DESCRIPTION: MDCRT-Critical Care Medicine Fellowship Competencies,
Norm Rizk, MD, Program Director
Competencies define procedures or activities that the resident/clinical fellow can usually perform without on site supervision: Patient management, including H&Ps and diagnostic and therapeutic treatments, procedures and interventions encompassing the areas described below and similar activities. The underlying patient condition and complexity of the procedure might dictate the need for direct supervision and physical presence of the attending physician. Whenever a question arises about resident/clinical fellow competency to perform a procedure independently, the attending physician should be consulted.
F1 First Year Critical Care Medicine Fellow Airway management, stable/unstable, trauma: Adult Arterial line -insert and remove: Adult Blood gases (arterial): Adult Cardiopulmonary resuscitation - closed: Adult Cardioversion: Adult Defibrillation: Adult Drug administration - intravenous: Adult Endotracheal suctioning: Adult Endotracheal/nasotracheal intubation: Adult Foley catheter - insert and remove: Adult Gastric lavage: Adult Laryngoscopy: Adult Lumbar puncture: Adult NG tube - insert and remove: Adult Other resuscitation: Adult Paracentesis/acute PD catheter: Adult Perform/interpret lab tests (spin Hct/do,UA/EKG/gram stain/peripheral smear/etc.): Adult Phlebotomy (including blood cultures): Adult Pulmonary artery catheter - insert and remove: Adult Thoracentesis: Adult Venous line - insert and remove: Adult ___________________________________________________ __________________ Program Director Date ___________________________________________________ __________________ Resident/Clinical Fellow Date
Current Status
F1 First Year Critical Care Medicine Fellow Detailed description of procedures Whenever a question arises about
resident/clinical fellow competency to perform a procedure independently, the attending physician should be consulted
Only procedurally oriented Does not inform the resident when to call for help Question from whom ?
SUPERVISION – 2011 (3 of 4) Programs must set guidelines for
circumstances and events where residents must communicate with appropriate supervising physicians. (Where is this?)
Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of the resident and delegate the appropriate level of patient care authority and responsibility. (what is sufficient – by specialty?)
Standards under old ACGME policies
Policy on Supervision Surgical supervision: All surgical cases are adequately supervised by qualified faculty; the level of supervision is at the discretion of the faculty member. The intensity of the resident supervision reflects graduated levels of responsibility based on individual skill and level of training. Clinical & outpatient experience: Residents are given the opportunity to see patients, establish provisional diagnoses, and initiate preliminary treatment plans within the framework of the outpatient clinics. Particular emphasis is placed on ensuring an opportunity for follow-up care of surgical patients, so that the results of surgical care may be evaluated by the resident. Faculty supervision is provided for outpatient clinics at all times. Hospital-based experience: Residents actively participate in the management of patients in the perioperative period, both in the intensive care and the non-acute patient care units. Frequent consultation with faculty members is an essential part of excellent clinical care and optimizes resident teaching. Supervision is provided for all inpatient consults. Scholarly pursuits: Each resident is provided a timeline for his/her research rotation to develop a research project that follows a format similar to NIH-R01 applicants. Resident research is not limited to the research block in the PGY-3 year and residents are encouraged to work with faculty on clinical research projects as they arise. Personal growth: At the start of the residency, each resident is assigned a faculty mentor. The resident should consult this individual for issues that may arise during residency, including personality issues related to faculty or fellow residents, performance issues, social issues, or general questions regarding the residency and their growth. The faculty mentor reports to the director of the residency program.
Current Status
Surgical supervision Clinical & outpatient experience
All surgical cases are adequately supervised by qualified faculty; the level of supervision is at the discretion of the faculty member
Faculty supervision is provided for outpatient clinics at all times.
SUPERVISION – 2011 (4 OF 4)
• In particular, during the PGY 1 year, residents must have supervision level 1 or 2a (see below)
• Levels of Supervision*. In the development and description of systems to oversee resident supervision and graded authority and responsibility, each program must use the following classification of supervision.
1. Direct Supervision —The supervising physician is physically present with the resident and patient
2. Indirect Supervision: a. Direct supervision immediately available – The supervising
physician is physically within the confines of the site of patient care, and immediately available to provide Direct Supervision
b. Direct supervision available – The supervising physician is not physically present within the confines of the site of patient care, is immediately available via phone, and is available to provide Direct Supervision
3. Oversight-The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
*VA 2005 Consensus Definition
Autonomy (the other side of the coin)
independence or freedom, as of the will or one's actions
“Need to take increasing ownership of patient assessment , clinical reasoning patient care and outcomes”
Tensions between Supervision and Autonomy
For the medical educator Imperative for quality care but There is also the need to grant
graduated autonomy to learners (desire to make decisions on their own)
For the resident : Resident remains responsible for his or
her diagnostic and treatment decisions but
Faculty oversight and guidance to maintain quality of patient care (concern over revealing a knowledge gap)
Supervision is the social contract between faculty and
resident The balance is achieved through
entrustment of the resident with specific professional activities at specific levels (O. ten Cate , 2010)1. No entrustment 2. Service provision under close supervision3. Limited supervision4. Acting independently 5. Supervising others
Ensuring the quality of supervision is the responsibility
of : Clinical faculty Residents
Others PD Regulatory bodies Accreditation agencies Consumer groups and US judiciary
Supervision is both Procedural and Cognitive
Monitor v. Measure
Monitor: is this happening ? Measure: How well is this happening?
How do we measure supervision?
Qualitative Components Quantitative Components Qualitative / Quantitative
Measurement Resident Surveys/Program Evaluations
Qualitative Components of Supervision
Providing helpful feedback to residents Availability of attending Stimuli to learningProfessionalism/ Interpersonal skills PresenceTreatment/Care Planning Autonomy
Quantitative Components
Time with resident : Direct contact with patient by attending Direct contact with resident contributing
to decision making and care plan Direct contact with resident giving
feedback Both qualitative and quantitative
measures of supervision have adequate to good psychometric characteristics (one is not necessarily better than the other )
What do we know about supervision from residents and
attendings?
Early in training Residents generally overestimate the level at
which they can perform (some exceptions) Attendings generally underestimate the level
at which residents can perform Both reach equilibrium late in training The higher acuity of the patient makes
even late in training residents ask for supervision
Suggesting additional considerations which impact quality and time for
supervision
Trainee Considerations : Trainees working proficiency Quality of the treatment plan presented Trainee’s learning curve (as understood by
supervisor) Level of training Trainee's self confidence Trainee’s awareness of limitations Lack of acquaintance of supervisor with trainee
Supervisor Considerations
Supervisors’ general experience more experienced supervisors allow
more autonomy Balance of perceived supervisory role
between patient responsibility (Care Provider) and resident education (Clinical Educator)
Legal Standards
Residents are held, in general, to the same standard of conduct as a practicing professional
Supervising faculty may be found negligent if the level of supervision is insufficient (McCough v. Hutzel Hospital, 225 ILCS 60) “It is their (specialists) advanced learning that enables them to judge the competency of the resident’s performance” includes authorization of treatment plan,
presence/availability at time of procedure
Circumstantial Considerations
Quality of the team to assist the trainee
Type of activity (high risk vs. low risk) Acuity of the patient Time of day
Next Steps
Individual RRC’s are now formulating guidelines
Need for new program specific supervision policies PGY Level Specific Knowledge, skills, attitudes
(competency based) Explicit supervisory role of the attending
Example
UTHSC Graduate Medical Education: Resident Supervision Policy