Surgical Resident Physician Supervision Policy
DEPT: MEDICAL EDUCATION
POLICY #: 8240.28
To define responsibility for supervision and accountability of Surgical Residents in various venues.
1. The Santa Barbara Cottage Hospital Surgical Residency Program recognizes and supports the importance of graded and progressive responsibility in graduate medical education. This policy outlines the requirements to be followed when supervising surgical residents. The goal is to promote assurance of safe patient care, and the surgical resident’s maximum development of the skills, knowledge, and attitudes needed to enter the unsupervised practice of medicine.
a) Supervising Physician: A faculty physician, or a more senior resident/fellow.
b) Supervision: Four levels of supervision are recognized. They are:
i) Direct: The supervising physician is physically present with the resident and the patient.
ii) Indirect supervision with direct supervision immediately available: The supervising physician is present in the hospital (or other site of patient care) and is immediately available to provide Direct Supervision. The supervisor may not be engaged in any activities (such as patient care procedure) which would delay his/her response to a resident requiring direct supervision. NOTE: A qualified supervisor must be in house 24/7 whenever a resident potentially requiring Direct Supervision or Indirect Supervision with direct supervision immediately available is on duty.
iii) Indirect supervision with direct supervision available: The supervising physician is not required to be present in the hospital or site of patient care, or may be in-house but engaged in other patient care activities, but is immediately available through telephone or other electronic modalities, and can be summoned to provide Direct Supervision.
iv) Oversight: The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
3. The Santa Barbara Cottage Hospital Surgical Residency Program establishes schedules which assign qualified faculty physicians, residents, or fellows to supervise at all times and in all settings in which residents of the Santa Barbara Cottage Hospital Surgical Residency Program provide any type of patient care.
4. 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.
5. Senior residents and fellows serve in a supervisory role of junior residents in recognition of their progress toward independence.
6. All residents, regardless of year of training, must communicate with the appropriate supervising faculty member. The supervising attending physician must be called as soon as possible for the following:
a) New admissions and consultations
b) Any significant deterioration in a patient’s condition
c) Any significant changes in a patient’s management
d) All procedures
7. In the unlikely event the supervising physician does not respond in a timely manner, the resident should attempt to have the operator contact the physician at home. If this is not immediately successful the back up on-call physician, as designated on the call schedule, should be notified. Additionally, the program director may always be notified.
8. Initially, all PGY-1 residents will be directly supervised for all of the “patient management” and “procedure” competencies listed below.
a) Patient Management Competencies:
i) Evaluation and management of a patient admitted to hospital, including initial history and physical examination, formulation of a plan of therapy, and necessary orders for therapy and tests.
ii) Pre-operative evaluation and management, including history and physical examination, formulation of a plan of therapy, and specification of necessary tests
iii) Evaluation and management of post-operative patients, including the conduct of monitoring, and orders for medications, testing, and other treatments
iv) Transfer of patients between hospital units or hospitals
v) Discharge of patients from the hospital
vi) Interpretation of laboratory results
vii) Initial evaluation and management of patients in the urgent or emergent situation, including urgent consultations, trauma, and emergency department consultations (ATLS required)
viii) Evaluation and management of post-operative complications, including hypotension, hypertension, oligurnia, anuria, cardiac arrhythmias, hypoxemia, change in respiratory rate, change in neurologic status, and compartment syndromes
ix) Evaluation and management of critically-ill patients, either immediately post-operatively or in the intensive care unit, including the conduct of monitoring, and orders for medications, testing, and other treatments
x) Management of patients in cardiac or respiratory arrst (ACLS required)
b) Procedural Competencies:
i) Performance of basic venous access procedures, including establishing intravenous access
ii) Placement and removal of nasogastric tubes and Foley catheters
iii) Arterial puncture for blood gases
iv) Carry-out of advanced vascular access procedures, including central venous catheterization, temporary dialysis access, and arterial cannulation
v) Repair of surgical incisions of the skin and soft tissues
vi) Repair of skin and soft tissue lacerations
vii) Excision of lesions of the skin and subcutaneous tissues
viii) Tube thoracostomy
x) Endotracheal intubation
xi) Bedside debridement
c) Each PGY-1 will have a procedural logbook and a patient management competency log book describing each patient management scenario with a space for supervisory comments and documentation of attendance. Once the resident has documented completion of the appropriate number for each competency, the logbook will be reviewed by the Program Director and an oral examination will be given. If the resident is deemed competent, the Program Director will sign off on the competency and the completed competency will be documented electronically into the hospital record. This will allow confirmation of any resident’s competency by any hospital employee. Should the Program Director not deem the resident competent, a remediation program will be implemented and additional scenarios/procedures will be assigned until competency proficiency has been successful.
d) All “patient management” competencies must be successfully completed prior to the second year of residency. All procedure competencies must be successfully completed prior to the third year of residency.
9. In every level of supervision, the supervising faculty member must review progress notes within 24 hours, as well as sign procedural and operative notes and discharge summaries.
10. Faculty members must be continuously present to provide supervision in ambulatory settings, and be actively involved in the provision of care, as assigned. Faculty supervision assignments must 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.
COTTAGE HEALTH POLICY
RECOMMENDED BY: J. Gauvin, MD DATE: 11/14
ORIGINAL POLICY EFFECTIVE DATE: 6/11
APPROVED BY: GMEC/E. Wroblewski, MD DATE: 1/18
DATE REVISED: 1/18