Residency Training Supervision & Accountability Policy

[Last updated: 05/01/2022]

Please reference Policies | UW Graduate Medical Education for additional definitions and background. This page is best viewed on desktop.

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 [inset method of identifying attending physician]to residents/fellows, faculty members, other members of the health care team, and patients. 

The Anesthesiology residents 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 each resident’s 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. 

Supervision Definitions 

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

Direct Supervision

• The supervising physician is physically present with the resident and patient during the key portions of the patient interaction; or
  • PGY-1 residents must initially be supervised directly with the supervising physician physically present during the key portions of the patient interaction.
• 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.  

Indirect Supervision

• The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance within 5 minutes and is available to provide appropriate direct supervision within 30 minutes.  

Oversight

• The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered. 

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 

PGY-1 Residents 

PGY-1 residents are initially directly supervised (see definitions above).

PGY-1 residents are primarily responsible for the care of patients under the guidance and supervision of the attending physician and senior residents.  They should generally be the point of first contact when questions or concerns arise about the care of their patients.  However, when questions or concerns persist, supervising residents and/or the attending physician should be contacted in a timely fashion.  PGY-1 residents are initially directly supervised and when merited will progress to being indirectly supervised with direct supervision immediately available (see definitions above) by an attending or senior resident.  In the Anesthesiology residency program, PGY1 residents are attached to various services including Medicine, Surgery, Otolaryngology, Emergency Medicine, etc. When rotating on non-Anesthesiology clinical services, the clinical responsibilities and supervision requirements will be determined by the service to which Anesthesiology residents are attached. Residents are required to familiarize themselves with the requirements of each service and services are required to make this information available to residents at orientation.  

When rotating on clinical services housed under the Department of Anesthesiology and Pain Medicine, PGY-1 residents will be directly supervised by an attending physician or senior resident when caring for all patients in the operating room and when caring for any patient receiving an anesthetic regardless of location.  When judged appropriate by the attending physician, PGY-1 residents may perform tasks such as obtaining a history and physical, consulting with other services, delivering test results and general communication with patients and other members of the care team under indirect supervision with direct supervision immediately available. 

Intermediate Residents (CA1 Residents) 

Intermediate residents may be directly or indirectly supervised by an attending physician or senior resident or fellow but will provide all services under supervision. They may supervise PGY-1 residents and/or medical students; however, the attending physician is responsible for the care of the patient. 

Direct supervision is required for all the following situations: 

• Induction of anesthesia (general, regional and MAC) 
• Critical periods during the course of perioperative care 
• Emergence from anesthesia (general, regional and MAC) 
• At any time during the course of the perioperative care of a patient when the attending and/or the resident determine a situation is critical such that direct supervision is required. (For example, in patients, procedures and/or situations related to subspecialty anesthesia or complex patients, procedures and/or situations). Residents must indicate to their supervising attending if they require direct supervision at any time during patient care. In this situation the supervising attending must ensure direct supervision is available either themselves or from another suitably qualified attending. 

Senior Residents (CA2 and CA3 Residents) 

Senior residents 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, junior and intermediate residents in recognition of their progress towards independence, as appropriate to the needs of each patient and the skills of the senior resident; however, the attending physician is responsible for the care of the patient. 

Direct supervision is required for all the following situations: 

• Induction of anesthesia (general, regional and MAC) 

• Critical periods during the course of perioperative care 

• Emergence from anesthesia (general, regional and MAC) 

• At any time during the course of the perioperative care of a patient when the attending and/or the resident determine a situation is critical such that direct supervision is required. (For example, in complex patients, procedures and/or situations). Residents must indicate to their supervising attending if they require direct supervision at any time during patient care. In this situation the supervising attending must provide direct supervision themselves or ensure another suitably qualified attending is providing direct supervision. 

Levels of Supervision for Common Specialty Clinical Activities and Invasive Procedures  

Please list each clinical activity/procedure by PGY-level, with specific CPR Level of Supervision language:  

*At the VA Puget Sound and Seattle Children’s hospital after hours and weekend coverage (once all operating room cases are finished) for residents holding the airway pager is indirect level 2b supervision. This includes coverage for tracheal intubation. However, the resident should always call for backup from their attending and if circumstances allow, wait for the attending to arrive before attempting tracheal intubation. 

In the Anesthesiology residency program, PGY1 residents are attached to various services including Medicine, Surgery, Otolaryngology, gynecology etc. When rotating on non-Anesthesiology clinical services, the clinical responsibilities and supervision requirements will be determined by the service to which Anesthesiology residents are attached. Residents are required to familiarize themselves with the requirements of each service and services are required to make this information available to residents at orientation.  

Circumstances and events in which Supervising Faculty Member(s) MUST be contacted

• At any time during the peri-operative care of a patient where significant changes occur in the patient’s condition.   

• At any time on the ICU or pain services where the resident has concerns about the patient’s condition. 

Supervision of Consults 

Residents performing consultations on patients are expected to communicate verbally with their supervising attending at the following time intervals:  

• As soon as possible after completing the consult, and at most within 24 hours of receiving the consult. 
• Any resident performing a consultation where there is credible concern for patient’s life or limb requiring the need for immediate invasive intervention MUST communicate directly with the supervising attending as soon as possible prior to intervention or discharge from the hospital, clinic or emergency department so long as this does not place the patient at risk.  If the communication with the supervising attending is delayed due to ensuring patient safety, the resident will communicate with the supervising attending as soon as possible.  Residents performing consultations will communicate the name of their supervising attending to the services requesting consultation.   

Examples of consults provided by anesthesiology residents include: 

• Consult for pre-operative evaluation and optimization
• Consult for provision of sedation
• Consult for airway management
• Consult for vascular access
• Consult for pain management
• Consult for post anesthesia management

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. 

Faculty Supervision Assignment 

Faculty supervision assignments are of varied duration depending on the specific clinical service, but range from 8 to more than 40 hours/week and therefore are of sufficient length to assess the knowledge and skills of each resident/fellow and to delegate to the resident/fellow the appropriate level of patient care authority and responsibility. 

Supervision of Handoffs 

Residents conducting hand-offs are expected to use structured verbal and electronic processes for patient transfers between services and locations.  In the UW Medicine operating rooms the Department of Anesthesia and Pain Medicine uses the IPASS tool to conduct structured handoffs. When rotating on services outside of the operating rooms at UW Medicine facilities, local policies and procedures should be followed.    

Residents may be supervised directly or indirectly when conducting hand-offs. PGY-1 residents should initially be directly supervised when conducting hand-offs.  

Faculty must assess resident and fellow readiness to move from direct to indirect supervision when conducting hand-offs and patient transfers using the following