XIII. Supervision Policy

Supervision Policy

Lines of Supervision  | Definitions | Supervision Policy

Lines of Supervision Revised February 11, 2020

PROGRAM ADMINISTRATION:

Linda M. Liau, MD, PhD, MBA   Chair  
Marvin Bergsneider, MD Resident Program Director
Ulrich Batzdorf, MD  Resident Program Ombudsman
Luke Macyszyn, MD  Associated Program Director, Wellness
Geoffrey P. Colby, MD, PhD  Curriculum Director
Colleen Bruton C-TAGME   Resident Program Administrator

Definitions

NEUROSURGERY HOUSESTAFF SUPERVISION GUIDELINES

Revised February 11, 2020

PURPOSE: These guidelines are established to ensure patient safety, enhance the quality of patient care, and improve the training experience of residents. Consistent with the philosophy of progressively increasing individual responsibility, these guidelines are intended to provide the trainee the opportunity for graded levels of responsibility on the part of the trainee.

SCOPE: These minimal guidelines apply to all residents enrolled in the Neurosurgery Resident Training Program, and attending surgeons of all integrated and affiliated facilities affiliated with the UCLA Neurosurgery Training Program.

FACILITIES: All locations must ensure appropriate supervision for all residents and a work environment that is consistent with proper patient care, the educational needs of the residents, and all applicable program requirements.  Please see Program Letters of Agreement (PLA) for Harbor-UCLA Neurosurgery, West Los Angeles Veterans Administration Neurosurgery, Santa Monica UCLA Neurosurgery, and Kaiser Los Angeles Medical Center Department of Neurosurgery for site-specific guidelines. 

1.0 DEFINITIONS:

1.1. Resident Program Director is the education leader with full authority and responsibility for the administration of the neurosurgery residency program.  The Residency Program Director is responsible for full compliance with standards of accrediting and certifying bodies

1.2. Vice Chief of Clinical Affairs is the faculty member who defines the levels of responsibilities for each year of training by preparing a description of clinical activities residents may perform (Goals and Objectives).  The Goals and Objectives must include a specific statement identifying any exceptions for individual residents, as applicable.

1.3. Attending physicians are faculty who have completed an approved training program in neurosurgery or neurology and have been granted institutional privileges to conduct, without supervision, all pertinent aspects of patient care including admission, consultation, relevant operations and invasive procedures, or other defined activities.

1.4. Chief resident physicians are designated by the Residency Program Director and may assume advanced administrative responsibilities necessary for the operation of the residency program.  Chief residents are enrolled in the ACGME accredited program but have not completed the full academic program leading to board eligibility.  These residents, while quite senior, are not independent and must be supervised by an attending physician.  Graduated levels of responsibility may allow a wide range of practice.  These residents are completing their final year of training.

1.5. Supervising resident physicians are enrolled in the training program and have, by virtue of demonstrated competence, been granted privileges to conduct, without supervision, hospital admission and discharge, and specified invasive or operative procedures.

1.6. Resident physicians are individuals enrolled in the accredited neurosurgery resident training program and participating in patient care under the direction of supervising practitioners.

1.7. Fellow is a physician enrolled in either an accredited or a non-accredited training program.  The Fellow has completed an ACGME-accredited residency and is board-eligible or board-certified.  The fellow is a licensed independent practitioner and may function as a supervising practitioner for other trainees.

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2.0 Supervision Policy

2.1 General Coverage and Communication

2.1.1. The level of supervision and communication between the attending physician and any resident physician will be sufficient to ensure that the clinical care delivered meets the established community standard of care.

2.1.2. The resident can identify and contact a responsible attending surgeon for a given patient at all times.

2.1.3. In the event that an attending surgeon will not be available to provide appropriate supervision, he or she must designate an alternate or covering attending and identify that person to the housestaff.

2.1.4. Ambulatory (outpatient) care: Pursuant upon hospital and practice stipulated policies, an attending physician will provide direct or indirect supervision of patient care. The supervising physician will provide oversight of indirect supervision, with review of encounters with feedback provided after care is delivered

2.1.5. Inpatient admissions:

2.1.5.1. An attending physician or supervising resident physician will be notified of the admission and such notification will be documented in the admitting resident physician's admission note.

2.1.5.2. An attending physician will personally see and evaluate each assigned inpatient admission within twenty-four (24) hours of admission, and provide oversight by co-signing the resident physician's admission note or create their own documentation.

2.1.6. Inpatient Care:

2.1.6.1. Resident physicians should maintain ongoing communication at least one (1) time per day with the designated attending physician or supervising resident physician.

2.1.6.2. The attending physician should document such communication by co-signing the resident physician's progress note, or the resident will include in the progress note that the case has been discussed with the attending physician.

2.1.7. It is understood that there is a mutual responsibility on the part of both the attending physician and resident physician to recognize the need for increased communication, and attending physician interaction in the following circumstances:

•·limited experience of the resident

•·increased acuity of the patient's condition (e.g. transfer to intensive care unit, need for higher level of clinical care, etc.)

•·higher risk of complication or mortality associated with the clinical intervention being considered

2.1.8 Lines of Supervision and Communication

2.1.8.1. Consistent with the philosophy of graded levels of responsibility, it is expected that the resident physician will directly communicate with, and be, in turn, supervised by the most senior supervising resident on their assigned surgical team.

2.1.8.2. It is expected that the most senior supervising resident physician will directly communicate with the designated attending physician.

2.1.8.3. In urgent or emergent situations, immediate communication with the attending physician by any resident on the team is expected.

In the event that a resident is unexpectedly unable to attend/perform assigned clinical work, the most senior resident of that service along with the Program Director (or representative) will discuss the potential impact of this absence with the affected Site Director. Should the abscence negatively impact patient care, the Program Director (or representative) will arrange for another resident, or physican extender, to cover the essential clinical responsabilities for the absent resident. 

2.2 Graduated Levels of Responsibility

Residents earn progressive responsibility for the care of the patient as part of the training program.  The attending physicians determine which residents will be allowed to perform specific clinical tasks within their assigned level of responsibility based on technical skill, professional judgment, and knowledge.  The primary consideration in determining level of responsibility is effective and efficient patient care. 

2.3 Invasive Procedures and Operations

2.3.1 Invasive Procedures: An invasive procedure is defined as a procedure with more than minimal risk that is performed outside of the operating room or interventional radiology suite.

2.3.1.1. Direct Supervision: An attending physician or supervising resident physician will be physically present during all critical and key portions of invasive procedures.

2.3.1.2. Indirect Supervision:

2.3.1.2.1. If an attending physician is not physically present within the hospital or other site of patient care, he or she must be immediately available by means of telephonic and/or electronic modalities, and must be available to provide or arrange direct supervision if needed.

2.3.1.2.2. A supervising resident physician must be is physically within the hospital or other site of patient care, and will be immediately available to provide direct supervision during the entire procedure.

2.3.2 Operations: An operation is defined as any procedure with more than minimal risk that is performed in the operating room or interventional radiology suite.

2.3.2.1. Direct Supervision:

2.3.2.1.1. An attending physician will provide direct supervision of supervising residents for all key portions of operations.

2.3.2.1.2. The attending physician or supervising resident will provide direct supervision of resident physicians during the operative procedure.

2.3.2.1 Indirect Supervision: An attending physician will provide indirect supervision, and be immediately available for direct supervision, of supervising residents for all non-key portions of operations.

2.3.2.2 The attending physician, supervising resident, resident physician, or Service Physician's Assistant or Nurse Practitioner will be physically present with the patient for all operations.

2.3.2.3 In the event that an attending physician is not physically present for an operation, the supervising resident physician will ensure that appropriate documentation of the attending physician's notification and approval of the operation was obtained prior to proceeding with the operation.

2.3.2.4. An attending physician, supervising resident, or Service Physician's Assistant will see and evaluate each patient prior to the operation and ensure that appropriate documentation of a preoperative note has been performed.

2.3.2.5. An attending physician is not required to be present during opening and closing of the surgical field unless the opening or closing is considered a critical or key portion of the operation.

2.3.3. An attending surgeon, supervising resident, or Service Physician's Assistant or Nurse Practitioner will ensure that an appropriate and adequate informed consent has been obtained and documented in the medical record.

2.3.4. An attending surgeon, supervising resident, or Service Physician's Assistant or Nurse Practitioner will ensure that appropriate documentation of the procedure has been included in the medical record at the time of the procedure or operation.

2.3.5. The attending surgeon will be present and participate in the pre-surgical Time-Out

3.0 CHIEF RESIDENT RESPONSIBILITIES

  • Advocate high quality patient care
  • Assume a leadership role
  • Responsible for the accuracy and timeliness of resident team medical and training records insuring that residents complete consult, operative, and discharge reports within the UCLA required guidelines
  • The Chief Resident insures that residents keep current and accurate records of their duty hours
  •  Insure that each institution's (UCLA, Harbor, VA, Santa Monica) cases are tallied monthly
  • Responsible for the accuracy of the on-call schedules
  • The Harbor Chief Resident is responsible for the accuracy and distribution of the Harbor-UCLA moonlighting schedule
  • Maintenance and accuracy of the resident vacation schedule
  • Supervision of subordinate physicians, including interns (PGY-1), and medical students.
  •  Record and maintain Quality Assurance data, keep accurate and up-to-date information in the QA database, and present data at the monthly QA conference.
  • Insure residents attend didactic conferences
  •  Insure NS1, PGY1, and Medical Students attend ICU teaching rounds
  •  Insure PGY1s have sufficient experience in the operating room
  • Liaison with nursing team, assuming a leadership role in Care Coordination meetings
  • Maintain a professional relationship with physician extenders and support staff
  • Manage/Supervise the activities of Service Physician's Assistants or Nurse Practitioners
  • Manage and administrate the clinical service and outpatient services at Harbor-UCLA and West Los Angeles VA.

Supervision Structure at Individual Hospitals

RONALD REAGAN UCLA MEDICAL CENTER:
Linda M. Liau, MD, PhD, MBA Chair
Marvin Bergsneider, MD Resident Program Director
Faculty Attendings
Chief Resident
Junior Residents
Interns
Medical Students

HARBOR-UCLA MEDICAL CENTER:
Duncan Q. McBride, MD Neurosurgery Chief of Service
Richard G. Everson, MD Coverage Director
Faculty Attendings
Chief Resident
Senior Resident
General Surgery Residents
General Surgery Interns

WEST LOS ANGELES VETERANS ADMINISTRATION HOSPITAL:
Jean-Philippe Langevin, MD  Neurosurgery Chief of Service
Faculty Attendings
Chief Resident
Senior Resident
General Surgery Intern

SANTA MONICA UCLA MEDICAL CENTER:
Langston T. Holly, MD  Neurosurgery Chief of Service and Vice-Chair, Clinical Affairs
Faculty Attendings
Senior Resident
Medical Students

KAISER LOS ANGELES MEDICAL CENTER:
Shayan Rahman, MD Site Director
Faculty Attendings
Neurosurgery Resident

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