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GME
Graduate Medical Education


Graduate Medical Education Policies and Procedures


Policy on Resident Supervision

PURPOSE:  

Graduate Medical Education provides an organized educational program with supervision until competency is documented while ensuring safe and appropriate care for patients.

Careful supervision and observation are required to determine the trainee’s abilities to perform technical and interpretive procedures and to manage patients. Trainees must be given supervised graded levels of responsibility while assuring safe care of patients.

This policy establishes the minimum requirements for resident supervision at clinical affiliate sites of the University of Illinois College of Medicine.  A clinical site may have additional requirements for resident supervision. Requirements by a site take precedence over this policy as do applicable laws.

Definitions:

The following definitions are used throughout this document:

Resident – A licensed physician with valid contract in a post-graduate medical education program accredited by the Accreditation Council for Graduate Medical Education (ACGME).

Licensed Independent Practitioner (LIP) - A licensed health professional who is qualified usually by license and an institutional credentialing process to practice independently.

Medical Attending – An LIP who is a member of the institution’s medical staff.

General Policy:   

It is the responsibility of program directors to establish detailed written policies describing resident supervision at each yearly level of resident training. These descriptions must be distributed (e.g. website) regularly to all residents, and LIPs.  At all times, patient care will be the responsibility of a licensed independent practitioner (LIP) with appropriate clinical privileges. The requirements for direct supervision or indirect supervision, either immediately available or available, or oversight supervision will be established by the program director for each residency program in accordance with the ACGME requirement and will be monitored through periodic program reviews, and with institutional oversight through the Graduate Medical Education Committee (GMEC) internal review process.  Generally, local site directors or faculty listed in the program letter of agreement oversee supervision for his/her site.  The classification of supervision required for residents at various levels of training must be consistent with the requirement for progressive increase in resident responsibility and applicable program requirements.

The policy and procedures for each program must be in compliance with an applicable accrediting body either by The Joint Commission (TJC) or another accrediting organization acceptable to the Centers for Medicare and Medicaid Services, and all other clinical accreditations standards summarized below:

Procedure

  1. Residents will be supervised by licensed independent practitioners (LIPs). The LIP must be credentialed for the specialty care and diagnostic and therapeutic procedures that they are supervising. The medical attending is ultimately responsible for the care of the patient.
  1. Each Program Director will define policies in his/her discipline to specify how trainees progressively become independent in specific patient care activities while still being appropriately supervised. Each Program Director will complete a listing of resident clinical activities that are permitted by year of training, the required level of supervision for each activity, and any requirements for performing an activity without direct supervision. Program Directors will submit their listing of clinical activities by postgraduate year to the office of the DIO and to GMEC for review yearly.
  1. Yearly, each Program Director will update the job descriptions and listing of residents, clinical activities, and level of supervision submitting these to the DIO and GMEC.
  1. The Program Director will ensure that supervision policies are distributed to and followed by trainees and the LIPs who supervise residents. Compliance with the resident supervision policy will be monitored by the Program Directors.
  1. Annually the Program Directors will determine if residents can progress to the next higher level of training. The requirements for progression to the next higher level of training will be determined by standards set by each Program Director. This assessment will be documented in the annual evaluation of the trainees.

Program specific policies - The residency programs will follow Program specific policies in addition to the GME Policy.

Approved by GMEC: 10/25/2013, 5/20/2016