Surgical Resident Physician Supervision Policy

DEPT: MEDICAL EDUCATION
POLICY #: 8240.28

GOAL

To define responsibility for supervision and accountability of Surgical Residents in various venues.

POLICY

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.

2. Definitions:

A) Supervising Physician: A faculty physician, or a more senior resident/fellow.

B) Levels of supervision: To promote appropriate resident supervision while providing for graded authority and responsibility, the program must use the following classification of supervision:

i) Direct Supervision: The supervising physician is physically present with the resident and during key portions of the patient interaction.

1) PGY1 residents must initially be supervised directly, as described in #8 below.

ii) 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. 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) 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, based on the needs of each patient and the skills of the individual resident or fellow.

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

viii) Evaluation and management of post-operative complications, including hypotension, hypertension, oliguria, 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 arrest (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

ix) Paracentesis or laparoscopic port placement

x) Endotracheal intubation

xi) Bedside debridement

C) Each PGY-1 will have a procedural logbook 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.

REFERENCES

Note: The program must define those physician tasks for which PGY-1 resident may be supervised indirectly, with direct supervision available, and must define “direct supervision” in the context of the program.

The program must define those physician tasks for which PGY-1 residents must be supervised directly until they have demonstrated competence as defined by the program director and must maintain records of such demonstrations of competence.

The program should use the template of definitions provided in the FAQ or a variation of the template to develop these definitions.

COTTAGE HEALTH POLICY

Original Policy Effective Date: 06/2011
Last Review Date: 1/2024
Last Revision Date: 1/2024
Owner Title: Surgery Residency, Program Director
Owner Approval Date: 1/2024
Committee Approval: Graduate Medical Education (GMEC)
Committee Approval Dates: 1/2024
VP Approval: CMO/VPMA
VP Approval Date: 1/2024