Supervision of Graduate Medical Education (GME) program

1.  ABBREVIATIONS AND DEFINITIONS

ACGME-I: Accreditation Council for Graduate Medical Education International

GME: Graduate Medical Education

DIO: Designated Institutional Official

GMEC: Graduate Medical Education Committee

2.  RATIONALE

According to ACGME-I requirements as below:

• III.C.6. Supervision and Accountability: The Sponsoring Institution must oversee supervision of residents/fellows consistent with institutional/program-specific policies and the mechanisms by which residents/fellows can report inadequate supervision and accountability in a protected manner that is free from reprisal.
• IV.B.2. The GMEC must monitor programs’ supervision of residents and fellows to ensure that supervision is consistent with:
  • provision of safe and effective patient care;
  • educational needs of residents and fellows;
  • progressive responsibility appropriate to residents’ and fellows’ level of education, competence, and experience; and,
  • other applicable Foundational and Advanced Specialty/Subspecialty Requirements.

3.  STATEMENTS

• Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to them the appropriate level of patient care authority and responsibility.
• Residents must be supervised either directly or indirectly with direct supervision immediately available.
• Programs must set guidelines for circumstances and events for which residents must communicate with appropriate supervising faculty members such as the transfer of a patient to the intensive care unit or end of life decisions.
• This policy is intended to guide the activities of residents in ensuring that patient care activities in which residents participate are appropriately supervised and documented during the course of their inpatient and outpatient training. This supervision should begin with the resident’s initial contact with the attending physician and the patient and continue through all contact the resident has with the Supervision is complete when all documentation of the hospital stays, or clinic visit is collected for the medical record. All resident patient care activities are to be conducted within the scope of their training programs.

All VinUniversity GME teaching facilities will adhere to current accreditation requirements as set forth by the Accreditation Council for Graduate Medical Education International (ACGME- I) and the Vietnam Ministry of Health for all matters pertaining to the resident training programs, including the level of supervision provided.

Each Program Director shall develop explicit, written descriptions of supervisory lines of responsibility for the care of patients. Such guidelines must be consistent with this Policy and must be communicated to all residents and all members of the program’s teaching staff. Residents must be provided with prompt reliable systems for communication and interaction with supervisory physicians. Residents must be supervised by attending physicians in such a way that the resident assumes progressively increasing responsibility according to their level of education, ability, and experience. The schedules for attending physicians must be structured to ensure that appropriate Level of Supervision (defined below) is readily available to residents on duty, particularly during on call periods. The level of responsibility accorded to each resident must be determined by the teaching staff according to the program-specific criteria for evaluation and promotion. Residents provide care to patients at VinUni affiliated teaching hospitals in a variety of teaching services with supervision provided by attending physicians (licensed, independent practitioners with appropriate clinical privileges). Residency training involves resident participation in a well-defined portion of patient care responsibility with increasing degrees of independence. Although all resident care is supervised and the attending physician is ultimately responsible for care of the patient, the proximity and timing of supervision as well as the specific tasks delegated to the resident physician depend on a number of factors including:

1. the level of training (i.e. year in residency) of the resident
2. the skill and experience of the resident with the particular care situation
3. the familiarity of the supervising physician with the resident’s abilities
4. the acuity of the situation and the degree of risk to the patient.

In addition, patient care provided by residents is guided by the goals and objectives of the specific educational curriculum of each training program.

4. DEFINITIONS: Levels of Supervision

 To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision:

1. Direct Supervision: the supervising physician is physically present with the resident and
2. Indirect Supervision:

1. 1. 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.
   2. 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.

3. Oversight – The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

5. PROCEDURES

 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.

1. Faculty members functioning as supervising physicians may delegate portions of care to residents, based on the needs of the patient and the skills of the residents.
2. Residents should inform patients of their respective roles in each patient’s care.
3. Senior residents (PGY2 and above) should 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.

Inpatient Care:

1. An evaluation of the appropriateness of patients’ admission to the teaching service will be made by an attending physician (prior to, or concurrent with the initial involvement of a resident in the care of each patient). Care will be taken to ensure that the attending physician and the resident will be fully knowledgeable about the medical condition of the patient and that the appropriate level of supervision is provided at all times.
2. The attending physician shall evaluate the patient in person and be in a position to confirm the findings of the resident and discuss the care plan within a timeframe appropriate for clinical circumstances.
3. At least on a daily basis (more often as the needs of the individual patient may dictate), the resident and the attending physician will review progress of the patient, make the necessary modifications in the care plan, plan family conferences as needed, and agree on the type and scope of documentation for the medical record.
4. When a patient develops a change in condition that the resident feels is potentially dangerous for that patient, the resident will contact the admitting/attending physician and report these developments. The resident may identify the need for that physician to see the patient at an agreed upon time to assist in the evaluation and treatment of such a patient.
5. At the time of discharge, the attending physician may delegate some of the discharge planning to the resident, and should review any discharge documents generated by the resident and must sign provide all required attestation statements.
6. The attending physician must ensure the completeness of the medical record, including the provision of additional comments in the progress notes.

Outpatient Care:

1. In order to ensure patient safety and quality patient care while providing the opportunity for maximizing the educational experience of the resident in the ambulatory setting, it is expected that an appropriately privileged attending faculty member will be available for Direct Supervision or Indirect Supervision with Direct Supervision immediately available during clinic hours. Patients followed in more than one clinic will have identifiable attending faculty for each clinic. Attending faculty members are responsible for ensuring the coordination of care that is provided to patients.
2. All outpatients should be seen by the attending faculty at all visits unless not required by program-specific ACGME-I requirements. The medical record should reflect the degree of involvement of the attending faculty, either by physician progress note or addendum.

Supervision of Resident Performing Procedures:

1. A trainee will be considered qualified to perform a procedure if, in the judgment of the supervising attending physician or the training program director and his/her specific training program guidelines, GME guidelines, the trainee is competent to perform the procedure safely and effectively. This judgment must be stipulated in writing and be made part of the trainee’s file and documented in the Residency Management System.
2. In the event that a given trainee is considered qualified to perform a procedure, that trainee may then certify the qualification of another trainee more junior than him/herself; with such approval again to be in writing and signed by the supervising attending physician or training program director.
3. Residents at certain year levels in a given training program may be designated as competent to perform certain procedures without direct supervision, based upon specific written criteria set forth and defined by the Program Director. In this instance, resident may perform routine procedures that they are deemed competent to perform (such as arterial line placement) for standard indications without prior approval or direct supervision of the attending physician. However, the attending physician of record will be ultimately responsible for all procedures.
4. Each program should maintain a list of procedures that residents may perform without direct supervision, the criteria for performing them without direct supervision and any applicable PGY level restrictions.
5. Residents may perform life-saving emergency procedures without prior approval or direct supervision when a patient’s life would be threatened by delay.
6. All outpatient procedures will have the attending physician of record documented in the procedure note, and that attending physician will be ultimately responsible for the procedure.
7. Program Directors will designate the PGY level at which each procedure in their specialty can be performed. Some Program Directors may choose to identify only the requirements for residents to perform certain clinical activities without direct supervision since not all procedures may easily be categorized by PGY level.

6. MONITORING

1. The adequacy of supervision and resident satisfaction with supervision will be evaluated during the Graduate Medical Education Committee Annual Program Evaluation.
2. The annual GME report provided to all participating institutions shall specifically address the adequacy of supervision policies, as required by ACGME-I standards.
3. The GMEC shall review all accrediting and certifying bodies’ concerns regarding supervision of resident and ensure that appropriate follow-up with corrective actions occurs as needed.

Please find Supervision Policy for Internal Medicine here: 240424_IM Supervision Policy