Supervision & Accountability Policy - Occupational & Environmental Medicine

Supervision & Accountability Policy - Occupational and Environmental Medicine (OEM) Program

Clinical Training Sites: Harborview Medical Center, VA Puget Sound, Kaiser Permanente WA

Background

OEM trainees receive four months of clinical training in each of the two years of the program. Some of the clinical training is observational, especially the subspecialty rotations such as pain medicine. The other eight months per year are spent doing graduate coursework and public health practicum work. The supervision policy is relevant to these locations where residents may have their own scheduled patients, including but not limited to Harborview OEM Clinic, VAPS Environmental Contaminants Clinic, VAPS Employee Health, VAPS Rehab Medicine, and Kaiser or Valley Community OEM Clinics.

Responsibilities and Accountability

Each patient must have an identifiable and appropriately-credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable Review Committee) who is responsible and accountable for the patient’s care. This information will be available through the electronic medical record to residents, faculty members, other members of the health care team, and patients.

The OEM residents, fellows, and faculty members must inform each patient of their respective roles in that patient’s care when providing direct patient care.

The program will provide the appropriate level of supervision for each resident based on level of training and ability, as well as patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation.

As part of their education program, residents are given graded progressive responsibility according to the individual’s clinical experience, judgment, knowledge and technical skill. Each resident must know the limits of their scope of authority, and the circumstances under which the resident is permitted to act with conditional independence.

In the UW OEM program, each resident checks out directly to a pre-assigned attending physician one-on-one in each clinic where the resident has a patient panel.

Supervision Definitions

To promote oversight of resident supervision while providing for graded authority and responsibility, the following levels of supervision are recognized:

1. Direct Supervision:
   1. the supervising physician is physically present with the resident and patient during the key portions of the patient interaction; or,
   2. 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.
2. 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.
3. Oversight: the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

In OEM clinics where residents have a patient panel, direct supervision is nearly always provided. In rare circumstances where residents are experienced and deemed competent, indirect with direct supervision immediately available may be provided.

Resident Competence & Delegated Authority

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.

The program director must evaluate each resident’s abilities based on specific criteria, guided by the Milestones.

Faculty members functioning as supervising physicians must delegate portions of care to residents based on the needs of the patient and the skills of each resident.

Clinical Responsibilities by PGY-Level

Background

OEM trainees enter the residency program at levels ranging from PGY2 with no work experience to PGY8 with years of practice experience. In Preventive Medicine training such as OEM, trainees are classified as Preventive Medicine 1 (PM-1) and Preventive Medicine 2 (PM-2).

PGY-1 Residents

PGY-1 residents are initially either directly supervised or indirect supervision with direct supervision immediately available (see definitions above). This is not applicable to OEM, as the program accepts trainees at the PGY-2 level or higher.

Intermediate Residents / corresponds to PM-1

Intermediate residents may be directly or indirectly supervised by an attending physician but will provide all services under supervision. They may supervise resident on electives from other specialties and/or medical students; however, the attending physician is responsible for the care of the patient.

Senior Residents/fellows / corresponds to PM-2

Senior residents/fellows may be directly or indirectly supervised. They may provide direct patient care, supervisory care or consultative services, with progressive graded responsibilities as merited. Senior residents or fellows should serve in a supervisory role to medical students and other learners, as appropriate to the needs of each patient and the skills of the senior resident/fellow; however, the attending physician is responsible for the care of the patient.

Levels of Supervision for Common Specialty Clinical Activities and Invasive Procedures

*All listed activities are non-invasive. OEM residents do not perform invasive procedures.

Circumstances and Events in which Supervising Faculty Member (s) MUST be Contacted

The attending physician must be notified if a patient has suicidal ideation. If a case is contested, such as patient disagreement with causality or return to work recommendations, and the attending could be involved in future litigation, the attending must be notified.

Supervision of Consults

Residents may be asked to perform consultations while on call. Residents performing consultations on patients are expected to communicate verbally with their supervising attending at the following time intervals: within 12 hours of when the consultation occurred.

Emergency Procedures

It is recognized that in the provision of medical care, unanticipated and life-threatening events may occur. The resident may attempt any of the procedures normally requiring supervision in a case where death or irreversible loss of function in a patient is imminent, and an appropriate supervisory physician is not immediately available, and to wait for the availability of an appropriate supervisory physician would likely result in death or significant harm. The assistance of more qualified individuals should be requested as soon as practically possible.

The appropriate supervising practitioner must be contacted and apprised of the situation as soon as possible.