I. Purpose of policy
This policy establishes supervision guidance for Residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited programs at Dartmouth Hitchcock.
II. Policy scope
This policy applies to all Residents, program directors, and faculty members in ACGME-accredited graduate medical education programs at Dartmouth Hitchcock.
III. Definitions
Resident: Any physician in an ACMGE-accredited graduate medical education program including residents and fellows.
Progressive Authority and Responsibility: The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members.
Telecommunication Technology: Electronic transmission of information over distances, in the form of telephone calls, text, images, and/or video.
IV. Policy statement
Supervisory guidance provides Residents with an educational program that is clinically and academically progressive and that complies with the requirements of the ACGME and the individual specialty boards.
- All ACGME-accredited programs must assure that Residents, and supervising or attending physicians, adhere to the following standards to optimize patient care and the educational experience.
- Program-Specific Supervision Policy: Every program must have a program-specific supervision policy located in the Residency Management System (MedHub) consistent with the GME Resident Supervision Policy and Review Committee (RC) requirements. Resident supervision via telecommunication technology may not be permitted based on RC guidelines.
- Levels of Supervision: Each program must use the following classifications of supervision:
- Direct Supervision:
- The supervising physician is physically present with the Resident during key portions of the patient interaction, or the supervising physician and/or patient is not physically present with the Resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.
- PGY-1 Residents must initially be supervised directly and cannot receive supervision through telecommunication technology
- Review Committees may choose not to permit supervision via telecommunication technology
- Programs may choose not to permit supervision via telecommunication technology and indicate so within the program-specific supervision policy
- The supervising physician is physically present with the Resident during key portions of the patient interaction, or the supervising physician and/or patient is not physically present with the Resident 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.
- With direct supervision immediately available: The supervising physician is physically within the confines of the 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 confines of the site of patient care, but is immediately available via 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.
- Direct Supervision:
- Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each Resident and delegate the appropriate level of patient care authority and responsibility.
- Each program is responsible for developing descriptions of the level of responsibility accorded to each Resident by rotation and Post Graduate Year (PGY) level. These descriptions must include identification of the mechanisms by which the Resident’s supervisor(s) and program director make decisions about each Resident’s progressive involvement and independence in specific patient care activities. In particular:
- The program director must evaluate each Resident’s abilities based on specific criteria established by the faculty of the training program. These criteria shall be guided by the ACGME specialty/sub-specialty specific Milestones.
- Supervising faculty members will delegate patient care activities to Residents based on the needs of the patient and the demonstrated abilities of the Resident.
- Senior Residents 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.
- In each training program, there will be circumstances in which all Residents, regardless of level of training and experience, must verbally communicate with appropriate supervising faculty. Programs must identify and put in writing circumstances in which verbal communication with Supervising Faculty is necessary. At a minimum, these circumstances will include:
- Emergency admission
- Consultation for urgent condition
- Transfer of patient to a higher level of care
- Code Blue Team activation
- Change in DNR status
- Patient or family dissatisfaction
- Patient requesting discharge AMA, or
- Patient death.
- General
- All patient care must be supervised by qualified faculty.
- On-call and clinical assignment schedules must be available at all clinical service locations so that Residents, nursing staff and ancillary personnel can easily identify the assigned Resident and their faculty supervisor.
- PGY-1 level residents must be supervised either directly or indirectly, with direct supervision immediately available. If indirect supervision is provided, such supervision must be consistent with RC policies, and PGY-1 Residents must meet established criteria in order to be eligible for indirect supervision.
- Faculty Responsibilities
- Routinely review Resident’s documentation in the medical record.
- Be attentive to compliance with institutional requirements such as problem lists, medication reconciliation, and additional field defined document priorities.
- Provide Residents with constructive feedback as appropriate.
- Serve as a role model to Resident in the provision of patient care that demonstrates professionalism and exemplary communication skills.
- Resident Responsibilities
- Each Resident is responsible for knowing the limits of the scope of authority and the circumstances under which the Resident is permitted to act with conditional independence.
- In recognition of the responsibility to the institution and commitment to adhere to the highest standards of patient care, Residents must routinely notify the responsible attending physician based on the above, as well as any additional circumstances identified in program-specific supervisory policy.
V. References
ACGME Institutional Requirements. (2022). Retrieved from ACGME.org
Common Program Requirements. (2022). Retrieved from ACGME.org
D-H Policy ID: 11276