I. POLICY STATEMENT
UCSF Medical Center requires active supervision of all Housestaff members by an appropriately credentialed Medical Staff member with the supervision documented in the medical record.
II. REASON FOR POLICY
The UCSF Medical Staff must define the process for supervision of Housestaff members when carrying out patient care responsibilities. All Housestaff members function under the supervision of appropriately credentialed Medical Staff members, pursuant to the Medical Staff members’ privileges. This policy:
describes the mechanisms for Housestaff supervision and evaluation,
explains how Housestaff competency descriptions are accessed by the Medical Staff; and
outlines the process for communication between the Graduate Medical Education Committee and the Medical Center Governing Body.
III. RELATED DOCUMENTS
- JCAHO Medical Staff Standards: 2.5, 6.9, & 6.9.1
- Medical Staff Bylaws, Rules and Regulations
- Housestaff Competency Checklists
- Graduate Medical Education Program Requirements/Evaluations
- Resident Review Committee Site Visits
IV. CONTACTS
Direct any questions about this policy to the Graduate Medical Education Office at (415) 476-4562 or the Medical Staff Office at (415) 353-1680.
V. DEFINITIONS
Accreditation Council for Graduate Medical Education (ACGME): The governing body which accredits residency and clinical fellowship programs. The five member organizations of the ACGME are as follows:
- American Board of Medical Specialties (ABMS)
- American Hospital Association (AHA)
- American Medical Association (AMA)
- Association of American Medical Colleges (AAMC)
- Council of Medical Specialty Societies (CMSS)
Medical Staff Member: Any practitioner who has been appointed to the Medical Staff.
Housestaff Member: Post-medical graduates and clinical fellows who are pursuing a defined course of study (ACGME-approved) at the UCSF under the supervision of faculty at the Medical Center.
Privileges: Clinical procedures/activities granted to licensed independent practitioners holding Medical Staff membership (e.g. Attending, Courtesy, Visiting)
Competency Checklist: Procedures that may be performed without direct supervision at each educational level specified.
Graduate Medical Education Committee (GMEC): The governing body which oversees the accredited residency and clinical fellowship programs composed of program directors and other faculty involved in resident fellow education, as well as peer-nominated residents and fellows.
Governing Body: The Regents of the University of California and any Governing Body committee or individual, including the Chancellor, authorized to act on behalf of the Governing Body.
Resident Review Committee (RRC): A national committee of physicians who are members of that specialty and expert in matters of residency training in that specialty. An RRC exists for each of the specialties in which certification is offered by a specialty board that is a member of the ABMS. Each RRC is sponsored by the AMA's Council on Medical Education, by the board that certifies physicians within that specialty, and in most cases, by the professional college or other professional association within the specialty.
Program Director: The faculty member responsible for the oversight of the residency and fellowship training program.
Participant: Resident and Clinical Fellows pursuing the requirements of a specific training program.
Department Chair: The individual who is responsible for the administration and oversight of their respective clinical service at the UCSF School of Medicine.
VI. PROCEDURES
A. Mechanisms for Supervision
Each Medical Staff member is responsible for the care provided to individual patients. All Housestaff function under the supervision of appropriately credentialed Medical Staff members via the following:
- Must be available to the Housestaff member in person or by telephone and able to be present within a reasonable period of time, if needed.
- Department published Call Schedules, prominently available, indicating the responsible attending to be contacted;
- Countersignature on History and Physicals, Operative Reports and Discharge Summaries;
- Note every three (3) days in the Medical Record
The Medical Staff member directs the care of the patient and provides supervision based on the nature of the patient’s condition, the likelihood of major changes in the management plan, the complexity of care and the experience and judgment of the Housestaff member being supervised.
Housestaff members as individuals must be aware of their limitations. Failure to function within graduated levels of responsibility or to communicate significant patient care issues to the responsible attending physician may result in the removal of the Housestaff member from patient care activities.
B. Competencies (Table of Procedures)
Below is a table of procedures indicating which procedure a surgical resident may perform, with and without supervision. In all cases the clinical situation, the experience of the specific resident and the judgment of the more senior residents and/or the responsible faculty member can modify these guidelines.
Legend
I=insert R=remove Ap=apply P=peds A=adult
Surgical residents PGY 1-4 require supervision for all procedures performed on patients < 2 yrs old, < 10 kg in weight
| PGY | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | ||
| airway management, stable/unstable, trauma | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| anesthesia | ||||||||||
| local | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| field block | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| peripheral nerve block | A/P | A/P | A/P | A/P | A/P | A/P | A/P | |||
| ankle-brachial index | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| arterial line (I/R) | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| arthrocentesis | ||||||||||
| lower extremity | A | A | A | A | A | A | A | |||
| upper extremity | A | A | A | A | A | |||||
| bladder (Foley) catheter (I/R) | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| bladder irrigation | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| blood gases (arterial) | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| bronchoscopy | A | A | A | A | A | A | ||||
| cardiopulmonary resuscitation | ||||||||||
| closed | A | A | A/P | A/P | A/P | A/P | A/P | A/P | ||
| open | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| cardioversion | A/P | A/P | A/P | A/P | A/P | A/P | ||||
| cast/splint (Ap/R) | ||||||||||
| for fracture | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| for immobilization/protection | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| central line (femoral/jugular/subclavian) | ||||||||||
| insert | A/P | A/P | A/P | A/P | A/P | A/P | A/P | |||
| remove | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| chest tube | ||||||||||
| insert | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| remove | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| colonoscopy, with/without biopsy | A | A | A | A | ||||||
| compartment pressure measurement | A | A | A/P | A/P | A/P | A/P | A/P | A/P | ||
| conscious sedation | A/P | A/P | A/P | A/P | A/P | A/P | ||||
| cricothyroidotomy | A | A | A/P | A/P | A/P | A/P | A/P | A/P | ||
| cultures (urine/sputum/wound) | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| cutdown | ||||||||||
| venous | ||||||||||
| insert | A/P | A/P | A/P | A/P | A/P | A/P | A/P | |||
| remove | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| arterial | ||||||||||
| insert | A/P | A/P | A/P | A/P | A/P | A/P | A/P | |||
| remove | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| defibrillation | A | A | A/P | A/P | A/P | A/P | A/P | A/P | ||
| Doppler study | ||||||||||
| venous | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| arterial | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| graft/fistula | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| drainage tube (fluid/blood/pus – not chest/mediastinal) | ||||||||||
| insert | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| remove | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| drug administration | ||||||||||
| intravenous | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| intra-arterial | A/P | A/P | A/P | A/P | A/P | A/P | A/P | |||
| esophagogastroduodenoscopy (EGD) | A | A | A | A | ||||||
| endotracheal suctioning | A | A | A/P | A/P | A/P | A/P | A/P | A/P | ||
| endotracheal/nasotracheal intubation | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| gastric lavage | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| incision & drainage, abscess/fluid collection/cyst | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| laceration repair | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| laryngoscopy | A/P | A/P | A/P | A/P | A/P | A/P | ||||
| long intestinal tube (I/R) | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| lumbar puncture | A | A | A/P | A/P | A/P | A/P | A/P | A/P | ||
| mediastinal tube | ||||||||||
| insert | A | A | A | A | A | A | ||||
| remove | A | A | A | A | A | A | A | A | ||
| nasal packing | ||||||||||
| anterior | A | A | A/P | A/P | A/P | A/P | A/P | A/P | ||
| posterior | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| nasogastric tube (I/R) | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| other resuscitation | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| other wound care – not debridement | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| (change/replace dressing; clean) | ||||||||||
| pacemaker/pacer wires, transthoracic | ||||||||||
| insert | A | A | A | A | A | A | ||||
| remove | A | A | A | A | A | A | A | A | ||
| pacemaker/pacer wires, transvenous | ||||||||||
| insert | A | A | A | A | A | A | A | |||
| remove | A | A | A | A | A | A | A | A | ||
| paracentesis/acute PD catheter | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| percutaneoue needle aspiration/drainage/biopsy | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| for fluid collection/cyst/abscess/mass | ||||||||||
| perform/interpret lab tests (spin Hct/do UA/EKG/ | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| gram stain/peripheral smear/etc) | ||||||||||
| pericardiocentesis | A | A | A | A | A | A | ||||
| peritoneal lavage | A | A | A/P | A/P | A/P | A/P | A/P | A/P | ||
| phlebotomy (including blood cultures) | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| pleurodesis | A/P | A/P | A/P | A/P | A/P | A/P | ||||
| rectal tube (I/R) | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| remove foreign body | A | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| sclerosis, other (eg, seroma) | A/P | A/P | A/P | A/P | A/P | A/P | ||||
| sigmoidoscopy/anoscopy | ||||||||||
| with biopsy | A | A | A | A | A | A | A | A | ||
| without biospy | A | A | A | A | A | A | A | A | ||
| sutures/staples (I/R) | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| Swan Ganz catheter | ||||||||||
| insert | A | A | A | A | A | A | A | |||
| remove | A | A | A | A | A | A | A | A | ||
| thoracentesis | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| thoracotomy, emergency | A | A/P | A/P | A/P | A/P | A/P | A/P | |||
| tracheotomy | A | A | A | A | A | A | A | |||
| umbilical artery catheter | ||||||||||
| insert | P | P | P | P | P | P | ||||
| remove | P | P | P | P | P | P | P | |||
| venous line (I/R) | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
| wound debridement | A/P | A/P | A/P | A/P | A/P | A/P | A/P | A/P | ||
Legend
I=insert R=remove Ap=apply P=peds A=adult
Surgical residents PGY 1-4 require supervision for all procedures performed on patients < 2 yrs old, < 10 kg in weight