Department of Anesthesiology:

 Faculty Supervision of Residents and Documentation

Effective July 2011

 

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

1.      Direct Supervision – the supervising physician is physically present with the resident and patient.

2.      Indirect Supervision:

·         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.

·         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.

 

           

 

Resident Supervision

  • Teaching staff schedules are structured to ensure adequate direct and indirect faculty supervision (in-house and home call) and consultation are readily available to anesthesiology residents on duty 24 hours a day, 365 days per year.
  • Residents are provided with rapid, reliable system for communicating with supervising faculty. All faculty carry personal pagers and/or cell phones and in addition the OR in house faculty carry Faculty Call pagers. In house faculty call rooms are near Operating Rooms and L&D for immediate availability.
  • Faculty supervision of residents and documentation of supervision must always meet the standards of medical direction as defined by Medicare regulations. This would meet the ACGME definitions of direct supervision or indirect with direct supervision immediately available.
  • Individual resident supervision is customized to provide for progressively increasing responsibility according to their level of education, ability and experience.
  • 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 level of responsibility accorded to each resident is determined by the teaching staff on an individual basis. The clinical responsibilities for each resident must be based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services. Faculty members functioning as supervising physicians should delegate portions of care to residents, based on the needs of the patient and the skills of the residents.
  • Faculty and residents are educated to recognize the signs of fatigue and apply policies to prevent and mitigate the potential negative effects on resident well-being and patient safety. Teams of in-house residents and faculty are on duty so breaks can be provided as needed. Home call teams act as back-up if needed.
  • Senior residents or fellows 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.
  • Each resident must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence. Goals and Objectives specific to each rotation and PGY level help define these limits.

 

The following is a synopsis of our departmental standards concerning the faculty involvement with patient care and medical direction of residents.  Details regarding policies and procedures for documentation of faculty services to the patients can be found in the Departmental Compliance Plan (Billing Compliance Plan:  Documentation and Verification of the Anesthetic Care, 3rd edition).

 

Anesthesia Care in the Operating Room

  • There is at least one faculty in the hospital 24 hours per day, 365 days per year to medically direct anesthesia care in the OR, PACU, and code responses.
  • The goal is for faculty to meet the standards of medical direction (as defined by Medicare regulations) for all patients independent of financial classification (see Billing Compliance Plan, p. 4).  In general, a faculty member should be present during the induction of anesthesia, during emergence from anesthesia, and should see the patient either in the PACU, the ICU, or on one of the hospital wards after the patient has recovered from anesthesia.  The faculty member should also be immediately available during the anesthetic to diagnose and treat any complications. While faculty is always present for critical periods and immediately available, the level of responsibility accorded to each resident is determined by the teaching staff on an individual basis. Residents must communicate with appropriate supervising faculty members, so faculty members are present for direct supervision of critical periods as defined by Medicare or patient condition.
  •  For each case, there should be a pre-op note, an induction note, an emergence note, and a post-op note written, dated, timed and signed by a faculty member.
  • This would meet the ACGME definitions of direct supervision or indirect with direct supervision immediately available.

 

 

Anesthesia Care in Labor and Delivery

  • There is at least one faculty in the hospital 24 hours per day, 365 days per year to medically direct or supervise anesthesia care in Labor and Delivery.
  • The goal is for the faculty to meet the requirements for direct or personal supervision (as defined by Medicaid regulations), including being immediately available at all times. (see Billing Compliance Plan, p. 10).  For each case, there should be a pre-op note, an intraop note, and a post-op note written, dated, timed and signed by the faculty member.
  • This meets the ACGME definitions of direct supervision or indirect with direct supervision immediately available.

 

Surgical Intensive Care Unit (SICU)

  • There is one faculty on call and available 24 hours per day, 365 days per year.
  • One faculty rounds on patients with the resident team at least twice a day on regular workdays and once a day on holidays and weekends.
  • Documentation standards for billing – see Billing Compliance Plan.
  • SICU meets the ACGME definitions of direct supervision or indirect with direct supervision immediately available except when call team on duty and then meets indirect supervision 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. Should immediate faculty assistance be required the OR or OB in-house faculty is available to provide direct supervision of SICU resident on call until home-call faculty can arrive.

 

Pain Management Consults and Procedures

  • There is one faculty on call and available 24 hours per day, 365 days per year.
  • For consult patients, the faculty rounds with residents on all patients at least once a day, including weekends and holidays.
  • The faculty is present for all procedures as per the Medicaid regulations on direct supervision (See Billing Compliance Plan, p. 13).
  • Pain Management meets the ACGME definitions of direct supervision or indirect with direct supervision immediately available except when call team on duty and then meets indirect supervision 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. Should immediate faculty assistance be required the OR or OB in-house faculty is available to provide direct supervision of resident on call until Pain home-call faculty can arrive.

 

St. Joseph and UTMB PGY-1 clinical base interns (non-anesthesia rotations)

  • As per ACGME guidelines, PGY-1 residents are supervised either directly or indirectly with direct supervision immediately available. Supervision is provided by attending physicians on each rotation. Faculty liaisons for each training site are identified in Program Letters of Agreement.

 

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