San Antonio Uniformed Services Health Education Consortium San Antonio, Texas I. Applicability Rheumatology Trainee Supervision Policy The SAUSHEC Rheumatology Supervision Policy has been approved by the rheumatology clinical competency committee (CCC). It applies to all supervising faculty and trainees in the fellowship or rotating on the rheumatology service. This policy is in support of the SAUSHEC Trainee Supervision Policy, the ACGME guidelines and the Internal Medicine and Rheumatology residency review committee (RRC). II. Definitions and Responsibilities A. A trainee is defined in this policy as a medical intern, resident or fellow who has graduated from a medical school, and is either in the first (intern) or subsequent post graduate training program in a specialty or subspecialty. B. A student as defined in this policy is someone who is currently enrolled in a allopathic or osteopathic school. C. A supervising staff provider (also known as the attending ) is a licensed independent practitioner (LIP) who is credentialed to supervise trainees and students. Supervising staff providers (LIPs) are ultimately responsible for all aspects of their patient s care within each SAUSHEC training facility D. Supervision constitutes any method of oversight of patient care for the purpose of ensuring quality of care and enhancing learning. The rheumatology service may supervise through a variety of methods. Some activities will require the physical presence of a staff provider, yet many aspects of patient care may be supervised by a more advanced fellow. The variety of methods for supervision include: 1. Direct Supervision the supervising physician is physically present with the resident and patient. 2. Indirect Supervision a. with direct supervision immediately available the supervising physician is physically within the treatment facility and is immediately available to provide Direct Supervision. b. with direct supervision available the supervising physician is not physically present within the treatment facility, but is immediately available by means of telephone and/or electronic modalities, and is available to provide Direct Supervision. 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234-4504
c. Oversight the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered. d. Program directors are the institutional officials designated by SAUSHEC and recognized by ACGME as having responsibility for all training activities within their training program. Program directors are responsible for the quality of educational experiences provided to trainees and for ensuring appropriate resident supervision. III. General Principles of Supervision A. The rheumatology fellowship and clinic is committed to ensuring patient safety, quality health care, and resident well-being. Careful supervision and observation is provided to determine the trainee s ability to gather and interpret clinical information, perform technical procedures, interpret procedures and safely manage patients. Although not privileged for independent practice, trainees are given progressively graduated levels of patient care responsibility while concurrently being supervised to ensure quality patient care. Each patient has a responsible supervising staff provider whose name is recorded in the patient record, who is available to the fellows/residents/students and who is involved with and takes responsibility for the patient care being provided by the trainees he/she is supervising. This information is also available to patients. Residents and faculty members of a health care team inform patients of their respective roles in each patient s care. B. Supervision of trainees are organized to provide gradually increased responsibility and maturation into the role of a judgmentally sound, technically skilled, and independently functioning privileged provider. The rheumatology program director and the CCC define how trainees in that program progressively become conditionally independent in specific patient care activities in his/her program while still being appropriately supervised by staff provider. Each fellow/resident will know the limit of his/her scope of authority and the circumstances under which he/she is permitted to act with conditional independence. C. Ultimately, the supervising staff is responsible for the care of the patient and for the conduct and performance of all trainees under his/her supervision, unless a trainee willfully disregards SAUSHEC, hospital or program policy or the directions of a staff supervisor; conceals his/her intentions or actions from a staff or supervisor; performs medical care outside the scope of normally delegated responsibility without the knowledge and approval of the supervisor; or fails to appropriately perform duties that would generally be expected at his/her level of training without staff knowledge of the specific activities. 2
D. Each program assigns faculty supervisors for all circumstances (ie on-call staff, clinic staff, procedure staff, etc) for a sufficient duration to enable them to adequately assess the knowledge and skills of each resident and thereby delegate the appropriate level of patient care authority and responsibility. The RRC specific guidelines are integrated into levels of supervision. E. SAUSHEC Associate Deans will be informed about reports submitted by patient care and patient safety committees that involve students, residents or fellows requiring staff supervision. IV. Rheumatology Program Supervision Policies A. Fellowship supervision policies are addressed with CCC reviews of fellows and allowing for progressive responsibilities for patient care and patient management based on the RRC and milestones over the continuum of the program. These policies will address the following: 1. Levels of Supervision as defined by the ACGME. a. Supervision of students, PGY-1, PGY-2, and PGY-3 trainees other than rheumatology fellows will involve Direct Supervision or Indirect Supervision with Direct Supervision immediately available. b. Supervision of PGY-4 and PGY5 rheumatology fellows will involve Direct Supervision or Indirect Supervision with Direct Supervision immediately available. The level of direct versus indirect supervision will change as the fellow progresses with acquired trainee competencies for various milestones. For example, the first day of fellowship a fellow may independently perform an H&P and present the case but the supervisor will provide direct supervision for the H&P by clarifying significant portions of the history and filling in gaps in the history and/or examination using teaching methods. As the fellow progresses in intervals of 3-6 months, the rheumatology CCC will discuss and progress each individual fellow based on their successful competency and milestone achievements for and during fellowship. It is expected that successful rheumatology fellows, by the end of their PGY-4 year, should be able to supervise a student or PGY1-3 resident before presenting a case to the supervising staff. c. Fellows must demonstrate advanced competencies prior to serving in a supervisory role and this is discussed at the CCC for each fellow. A fellow cannot supervise any procedure unless they are signed off as competent to perform that procedure. For example, a fellow may be competent and signed off as competent for 3
performing a trochanteric bursa injection but may not be signed off as competent in performing a glenohumeral joint injection until a later date. B. The procedures listed below constitute the minimum expected achievement during the rheumatology fellowship. Rheumatology fellows will keep a log of their procedures on the New Innovations web site. When fellows have achieved the minimum number of a given procedure and when the fellow feels proficient in that procedure, the CCC will review the progress of that fellow and vote to allow the fellow to do the procedure independently. The CCC will judge whether the fellow needs additional experience, based on faculty member observations of the fellow. Procedure List Guideline, Rheumatology Fellowship Procedure Specific sites involved Minimum number for certification* Polarizing microscopy All synovial joints 2 Simple bursal injection Trochanteric, pes anserine, 2 Bursal drainage and/or injection Peri-tendinitis injection Knee Wrist Elbow Ankle Shoulder Small joint Myofascial trigger point injection Olecranon, prepatellar, superficial and deep infrapatellar, other less ommon or adventitial bursae Lateral epicondyle, APL/EPB tendon sheath (DeQuervain s), Trigger finger, long head of biceps, other less common tendons, carpal tunnel injection, plantar fascia calcaneal insertion injection Knee joint proper 2 (documentation from residency is acceptable) Wrist, dorsal approach 2 Elbow joint proper 2 Ankle, anterior lateral or 2 medial ankle mortise Anterior or posterior 3, with at least one being glenohumeral joint glenohumeral, AC joint, and rotator cuff peritendon injection MCP, PIP, DIP, MTP joints 2 Head/neck/trunk/gluteal regions 4 3 3 2
Accomplishing the minimum does not mean competency; this is determined by the learner and the education committee. More than the minimum may be deemed necessary. C. Supervision by year level: It is expected that first year fellows will become independent in knee and bursal procedures within the first six months of the fellowship, and will continue to add more procedures during their fellowship. Supervision of first year fellows is by close direct observation with extensive formative feedback to ensure sterile technique, adequate informed consent, and patient comfort. Second year fellows should have achieved independence for most procedures by January of their second year. Supervision of second year fellows is mainly for accomplishment of that particular technical route of injection. All procedures are reviewed and evaluated by the faculty member in New Innovations. V. Staff Confirmation of Trainee Procedural Competencies A. Posting of fellow procedures: Procedures for which fellows have achieved competence are placed on the rheumatology drive for current reference. Inpatient ward personnel wishing to verify a fellow s credentials in a given procedure may page the staff rheumatologist on call regarding this information. B. The rheumatology supervision policy is reviewed annually at the end of year CCC and distributed to fellows and supervising staff. Programs will notify the DIO or ADGME of any near miss or adverse patient outcome where supervision procedures were deemed as contributory. In addition, Program Directors will provide a plan of action to the GMEC to prevent reoccurrences. Any problematic issues will be reported to the governing bodies of BAMC. Supervision policies are available on the SAUSHEC website at: http://www.bamc.amedd.army.mil/saushec/index.asp VI. Documentation of Staff Supervision A. Documentation in writing, by staff and trainees, must be in accordance with hospital policies. B. Staff supervision of patient care must be documented in the record as specified in the treatment facility and/or program supervision policies. VII. Trainee Grievances Regarding Supervision A. Program directors are responsible for ensuring that trainees are aware that their concerns regarding adequate technical or professional supervision or professional behavior by their supervisors will be addressed in a safe and non-threatening environment per SAUSHEC and ACGME guidelines. 5
B. Any trainee grievance can be addressed directly from a trainee to a trusted supervisor on the rheumatology rotation. This grievance will be presented to the program director or associate program director as necessary to address the issue. 6