Supervision Policy

Roles, Responsibilities and Patient Care Activities of Residents

Oral & Maxillofacial Surgery

Harborview Medical Center; Northwest Center for Oral & Facial Surgery; UWMC-Montlake, UWMC-Northwest; Seattle Children’s Hospital; VA Puget Sound Medical Center; Swedish MC- Ballard Campus

Definitions

Resident

Residents are Dentists returning for specialty training in Oral & Maxillofacial Surgery. During their residency, they will acquire a medical degree (MD). They learn the skills necessary for their chosen specialty through didactic sessions, scholarly activities and providing patient care under the direction and supervision of Oral & Maxillofacial Surgery, Medical and Surgical Staff (the Attendings). The term “resident” includes all residents and fellows including individuals in their first year of training (PGY1), often referred to as “interns”. As part of their training program, residents are given graded and progressive responsibility according to the individual residents’ clinical experience, judgment, knowledge, and technical skill. Each resident must know the limits of his/her scope of authority and the circumstances under which he/she is permitted to act with conditional independence. Residents are responsible for asking for help from the supervising attending for the service they are rotating on when they are uncertain of diagnosis, how to perform a diagnostic or therapeutic procedure, or how to implement an appropriate plan of care.

Attending of Record (Attending)

An identifiable, appropriately credentialed and privileged attending oral and maxillofacial surgeon with a faculty appointment in the UW OMS department, UW physician or licensed independent practitioner as approved by outside rotation review committee who is ultimately responsible for the management of the individual patient and for the supervision of residents involved in the care of the patient. The attending delegates portions of care to residents based on the needs of the patient and the skills of the residents.

Supervision

To ensure oversight of resident supervision and graded authority and responsibility, the following levels of supervision are recognized:

1. Direct Supervision – the supervising physician is physically present with the resident andpatient.
2. Indirect Supervision:
   1. with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care and is immediately available to provide Direct Supervision within 15 minutes
   2. with direct supervision available – the supervising physician is not physically presentwithin the hospital or other site of patient care but is immediately available by means oftelephonic and/or electronic modalities and is available to come to the site of care inorder to provide Direct Supervision.
3. Oversight – the supervising physician is available to provide review ofprocedures/encounters with feedback provided after care is delivered.

Clinical Responsibilities

Residents are part of a team of providers caring for patients. The team includes an attending and may include other licensed independent practitioners, other trainees and students. The attending oral and maxillofacial surgeon with a faculty appointment in the UW OMS department, UW physician or licensed independent practitioner as approved by outside rotation review committee has ultimate responsibility for the patients under their care as outlined in the Department of Oral & Maxillofacial Surgery Policy for Resident Supervision. Residents may provide care in both inpatient and outpatient settings. They may serve on a team providing direct patient care or may be part of a team providing consultative or diagnostic services. Each member of the team is dedicated to providing excellent patient care.

Residents evaluate patients, obtain the medical history and perform physical examinations. They may develop a differential diagnosis and problem list. Using this information, they develop a plan of care in conjunction with other trainees and supervising attending. They may document the provision of patient care as required by hospital/clinic policy. Residents may write orders for diagnostic studies and therapeutic interventions as specified in the medical center bylaws and rules/regulations. They may interpret the results of laboratory and other diagnostic testing. They may request consultation for diagnostic studies, the evaluation by other physicians, physical/rehabilitation therapy, specialized nursing care, and social services. They may participate in and/or perform procedures in the operating room, outpatient clinic, inpatient wards, emergency department or any other procedural area under appropriate supervision. Residents may initiate and coordinate hospital admission and discharge planning. Residents discuss the patient’s status and plan of care with the supervising attending and the team regularly. All residents help provide for the educational needs and supervision of any junior residents and students.

The clinical responsibilities for each resident are based on PGY-level, patient safety, resident education, severity and complexity of patient illness/condition and available support services. The specific role of each resident varies with their clinical rotation, experience, duration of clinical training, the patient’s illness and the clinical demands placed on the team. The following is a guide to the specific patient care responsibilities by year of clinical training. Residents must comply with the supervision standards of the service on which they are rotating unless otherwise specified by their program director.

Please note that during their 6-year residency training, some residents may be engaged in completion of Medical School, or completion of General Surgery rotation [During which time, residents follow the supervision policy designated by General Surgery]. Only years of OMS clinical training are considered below.

OMS PGY-1 (Interns)

PGY-1 residents are primarily responsible for the care of patients under the guidance and supervision of the attending physicians and senior residents. They should be the point of first contact when questions or concerns arise about the care of their patients unless the complexity of care necessitates a more senior individual discussion. All questions directed at them are discussed with the senior residents and/or attending supervisors. They do not make decisions independently until the attending feels they are proficient in that portion or portions of learning. They may provide emergency services and consultation under the supervision of the chief residents and attendings. PGY-1 residents are initially directly supervised and when merited they will progress to being indirectly supervised with direct supervision immediately available by an attending or senior resident when appropriate.

OMS PGY-4 (General Surgery year)

Residents board with the Department of Surgery for the duration of PGY4 at 100% FTE functioning as a General Surgery Intern and fall within the scope of the General Surgery Program’s resident supervision policy.

OMS PGY-5 Senior

OMS residents assume more direct responsibility for the care of patients in the inpatient and outpatient settings including the operating room, intensive care unit and the emergency department. They also participate in the day-to-day management of patients on surgical services and provide consultation under the indirect supervision of the Chief resident and attending. They may provide direct patient care or consultative services with indirect supervision. They may provide emergency services and consultation under the supervision of the chief resident and attending. They may supervise PGY-1 residents and/or students; however, the attending physician is ultimately responsible for the care of the patient. The senior resident may progress to be the lead assistant surgeon and the primary surgeon, under direct attending supervision.

PGY-6 (Chief Residents)

Chief residents are in their final year of clinical training. These residents are surgical team leaders. They have inpatient and/or outpatient responsibilities and are responsible for the overall smooth running of the OMS service to which they are assigned. They are the lead assistant surgeon and often the primary surgeon, under direct supervision. They are responsible for supervising and coordinating the teaching of junior-level OMS residents and students. The attending physician is ultimately responsible for the care of the patient.

Attending of Record

In the clinical learning environment, each patient must have an identifiable, attending oral and maxillofacial surgeon with a faculty appointment in the UW OMS department, UW physician or licensed independent practitioner as approved by outside rotation review committee who is ultimately responsible for that patient’s care. The attending physician is responsible for assuring the quality of care provided and for addressing any problems that occur in the care of patients and thus must be available to provide direct supervision when appropriate for optimal care of the patient and/or as indicated by individual program policy. The availability of the attending to the resident is expected to be greater with less experienced residents and more with increased acuity of the patient’s illness. The attending must notify all residents on his or her team of when he or she should be called regarding a patient’s status. In addition to situations the individual attending would like to be notified of, the attending should include in his or her notification to residents all situations that require attending notification per program or hospital policy. The primary attending physician may at times delegate supervisory responsibility to a consulting attending physician if a procedure is recommended by that consultant. For example, if an oral and maxillofacial surgeon is asked to consult on a patient on the medicine service and decides the patient needs an incision and drainage of an abscess, the medicine attending may delegate supervisory responsibility to that oral and maxillofacial surgeon to supervise the medicine resident who may perform the incision and drainage. This information should be available to residents, faculty members, and patients.

The attending may specifically delegate portions of care to residents based on the needs of the patient and the skills of the residents and in accordance with hospital and/or departmental policies. The attending may also delegate partial responsibility for supervision of junior residents to Chief Residents assigned to the service, but the attending must ensure the competence of the senior resident before supervisory responsibility is delegated. Over time, the Chief Resident is expected to assume an increasingly larger role in patient care decision making. The attending remains responsible for assuring that appropriate supervision is occurring and is ultimately responsible for the patient’s care. Residents and attendings should inform patients of their respective roles in each patient’s care.

The attending and supervisory residents are expected to monitor competence of more junior residents through direct observation, formal ward rounds and review of the medical records of patients under their care.

Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility.

Supervision of invasive procedures

In a training program, as in any clinical practice, it is incumbent upon the resident to be aware of his/her own limitations in managing a given patient and to consult a resident or attending with more expertise when necessary. When a resident requires supervision, this may be provided by a qualified member of the medical staff or by a resident who is authorized to perform the procedure independently. In all cases, the supervising attending is ultimately responsible for the provision of care by residents. If there is any doubt about the need for supervision, the attending should be contacted.

The following procedures may be performed with the indicated level of supervision:

Direct supervision required by a qualified member of the medical staff

• All Operating Room Procedures
• All Sedation for Procedures *
• Elective Intubation in the OR;
• All other invasive procedures not listed

Direct supervision required by a qualified member of the medical staff unit until the procedure has been performed by the resident under direct supervision, and resident is deemed competent to perform independently by attending or Chief and/or Senior-level resident:

Minor Oral & Maxillofacial Surgery Procedures

• All Sedation for Procedures *
• Dental extractions,
• Dentoalveolar surgery,
• Stabilization of dentoalveolar and maxillofacial fractures,
• Closed TMJ manipulations,
• Repair of soft tissue lacerations,
• Incision and drainage of abscesses (not including those in the neck).

*All Sedation procedures where the resident is the operator anesthesiologist MUST have direct attending supervision until the resident is deemed competent to perform the cases independentlyby the Attending OMS surgeon.

*OMFS Residents are allowed to administer anesthetic agents including ketamine, and propofol, provided they have already completed the first block of rotation through anesthesia. The OMFS attending, who also needs to be qualified to administer anesthetic agents, should be immediately available (in the hospital), but need not be physically present at the time of administration. (HMC moderate sedation/ Analgesia for Procedures by Non-Anesthesia Care Providers [APOP 80.3])

Other procedures

• Placement of peripheral intravenous catheters;
• Dressing changes;
• Suture placement and removal;
• Cryotherapy;
• Silver nitrate cauterization therapy;
• Nasogastric intubation;
• Minor bedside procedures;
• Beginning surgical cases in the OR or Clinic procedure room.

Procedures performed during off-service rotations

OMS residents on the general surgery rotations participate in a Joint Intern Orientation Program.

They must pass an Evaluation and Management (E&M) Cognitive Test and a Procedural Skills Test which include the procedures listed below. These procedures are directly or indirectly supervised by the GS attending surgeons and/or senior level GS residents, according to the GS supervision policy.

• Arterial cannulation
• Advanced vascular access procedures, including central venous catheterization and temporary dialysis access
• Arterial puncture for blood gases
• Basic venous access procedures, including establishing intravenous access
• Bedside wound debridement
• Excision of lesions of the skin and subcutaneous tissues (including Hickman and Port removals)
• Paracentesis
• Placement and removal of nasogastric tubes
• Placement and removal of Foley catheters
• Repair of surgical incisions of the skin and soft tissues
• Repair of skin and soft t issue lacerations
• Tube thoracostomy

Indirect supervision required with direct supervision immediately available by a qualified member of the medical staff for the (Same as above, after certification of competence by attending).

Indirect supervision required with direct supervision available by a qualified member of the medical staff (Same as above, after certification of competence by attending).

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.

Supervision of Consults

Residents may provide consultation services under the direction of supervisory level residents. The attending of record is ultimately responsible for the care of the patient and thus must be available to provide direct supervision when appropriate for optimal care and/or as indicated by individual program policy. The availability of the attending and supervisory residents or fellows should be appropriate to the level of training, experience and competence of the consult resident and is expected to be greater with increasing acuity of the patient’s illness. Information regarding the availability of attendings and supervisory residents or fellows should be available to residents, faculty members, and patients. Residents performing consultations on patients are expected to communicate verbally with their supervising attending at regular time intervals on a daily basis. 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.

Supervision of Hand-Offs

Each program must have a policy regarding hand-offs. This policy must include expectations of supervision with each type of hand-off situation. The Chief resident on call will provide a verbal and/or written handover to the Chief resident on site at or prior to 8am the day after call is completed. The junior resident or intern will provide a verbal and/or written handover to their counterpart at the appropriate site after reviewing all the handover communication with the Chief resident and /or the attending. In some circumstances handover will occur during ward rounds when the incoming and outgoing on call residents will discuss patient care. Smooth handovers and continuity of patient care will be assessed by the primary supervising attending.

Verbal Communication During Sign-Out Checklist

Who, What, Where, When, and How

• WHO should participate in the sign-out process?
  • Outgoing clinician primarily responsible for patient’s care
  • Incoming clinician who will be primarily responsible for patient’s care (avoid passing this task to someone else, even if busy)
  • Consider supervision by experienced clinicians if early in training
• WHAT content needs to be verbally communicated? Use situation briefing model, or SBAR, technique:
  • Situation—Identify each patient (name, age, sex, chief complaint) and briefly state any major problems (active and those that may become active during cross coverage).
  • Background—pertinent information relevant to current care (eg, recent vitals and/or baseline exam, labs, test results, etc.); advanced directives code status.
  • Assessment—working diagnosis, response to treatment, anticipated problems duringcross-coverage including anything not adequately described using written form (eg,complex family discussions).
  • Recommendation—to-do lists and if/then recommendations.
• WHERE should sign-out occur?
  • Designated room or place for sign-out (eg, avoid patient areas because of HIPPA requirements)
  • Minimize disruptions
  • Ensure systems support for sign-out (eg, computers, printer, paper, etc.)
• WHEN is the optimal time for sign-out?
  • Designated time when both parties can be present and pay attention (eg, beware of clinic, other obligations)
• HOW should verbal communication be performed?
  • Face to face, allowing for questions
  • Verbalize data in the same order for each patient at each sign-out
  • “Read back” all to-do items
  • Adjust length and depth of review according to baseline knowledge of parties involved and type of transition in care

Circumstances in which Supervising Practitioner MUST be Contacted

There are specific circumstances and events in which residents must communicate with appropriate supervising faculty members. Additional requirements will be discussed with the supervising attending as needed by clinical site. If the supervising attending is not available, any other attending can be contacted whose primary site of responsibility is the location of question. All site attendings are aware of their primary and secondary backup requirements.

• Oms Attending Call Triggers – Attending MUST be contacted:
• Airway compromise, requiring intubation, ICU monitoring, and/or admission – any service where OMS is directly involved or consulted
• Uncontrolled bleeding
• Emergent intervention in the OR with OMS
• Admission to the hospital or patient leaving AMA (when OMS is the primary team)
• Life threatening event (i.e., Cardiac arrest, code blue, death) – or increased morbidity to the patient irrespective of whether or not this was anticipated
• Clinical deterioration of patient
• Hemodynamic instability, including unstable arrhythmias/vital signs
• Development of significant neurological changes (suspected CVA/seizures/new onset paralysis)
• Inpatient discharge from hospital (when OMS is the primary team)
• Medication or treatment errors requiring clinical intervention or when a PSN (patient safety note) is written
• If nurse or other attending requests attending notification
• If any trainee feels that a situation is more complicated than he or she can manage

The on-call attending should be informed of and updated on all in-house patients. If the primary attending of record is covering their own patient (while not being the listed on-call attending, e.g., the oncology patient’s) the on-call attending must be notified and aware.

Outpatient Settings

Office visits. All patients seen by residents at hospital site office visits must be directly supervised by the attending physician, except those under the “evaluation and management of a new patient exception”, which is as follows Applies only to office codes 99201, 99202, and 99203, and 99211, 99212, and 99213 (thefirst three levels of new patient and established patient office visits)

•Allows the attending physician to discuss the history, physical, and plan of care with the resident and confirm these elements without actually seeing the patient; however, each must be discussed before the end of that clinic.

All other visits (e.g., emergency room), The attending physician must directly supervise all patients seen by residents for the visit to be billed. If only indirect supervision or oversightis provided by the attending, the visit is not to be billed.

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 evaluates each resident’s abilities based on specific criteria. The residency program uses multifaceted assessment process to determine a resident’s progressive involvement and independence in providing patient care. Residents are observed directly by the attending staff and their performance discussed regularly. Informal assessments are generally obtained after each rotation and are based from supervising faculty attending providers, students and colleagues. These assessments include evaluation of the residents’ clinical judgement, medical knowledge, technical skills, professional attitudes and behavior, and overall ability to manage the care of a patient. The American Association of Oral and Maxillofacial Surgeon (AAOMS) benchmarks are used in this assessment process. The program director and full-time OMS faculty meet biannually to assess the trainee progress. This meeting is to identify early weakness or limitations that may require additional supervision or training. Annually, the program director and residency review committee determine if the trainee possess sufficient training and qualifications necessary to be promoted to the next level.

Resident Review and Promotion Process

The residency program uses a multifaceted assessment process to determine a resident’s progressive involvement and independence in providing patient care. Residents are observed directly by the attending staff and their performance discussed regularly. Formal assessments are generally obtained after each block rotation and are from attending oral and maxillofacial surgeons, supervising physicians, staff and colleagues. These assessments include evaluation of the resident’s clinical judgment, medical knowledge, technical skills, professional attitudes, behavior, and overall ability to manage the care of a patient. The (AAOMS) benchmarks are used in this assessment process. The program director and full-time OMS faculty meet biannually to assess the trainee progress. This meeting is to identify early weakness or limitations that may require additional supervision or training. Where concerns are raised regarding a specific trainee, the faculty may convene earlier. Annually, the program director and Oral & Maxillofacial Surgery faculty meet to determine if the trainee possess sufficient training and the qualifications necessary to be promoted to the next level Trainees are evaluated continuously by the attending staff as outlined in the Department of Oral & Maxillofacial Surgery Residency Program Policy. If a trainee’s clinical activities are restricted (e.g., they require a supervisor’s presence during a procedure after having been certified competent), then the Medical Director’s office will be notified

Faculty Development and Resident Education around Supervision and Progressive Responsibility

Residency programs must provide faculty development and resident education on best practices around supervision and the balance of supervision and autonomy.

One best practice to consider is the SUPERB SAFETY model.

Attendings should adhere to the SUPERB model when providing supervision. They should:

1. Set Expectations: set expectations on when they should be notified about changes inpatient’s status.
2. Uncertainty is a time to contact: tell the resident to call when they are uncertain of a diagnosis, procedure or plan of care.
3. Planned Communication: set a planned time for communication (i.e., each evening, on callnights)
4. Easily available: Make explicit your contact information and availability for any questionsor concerns.
5. Reassure resident not to be afraid to call: Tell the resident to call with questions or uncertainty.
6. Balance supervision and autonomy.

Residents should seek supervisor (attending or senior resident) input using the SAFETY acronym.

1. Seek attending input early
2. Active clinical decisions: Call the supervising resident or attending when you have a patient whose clinical status is changing, and a new plan of care should be discussed. Be prepared to present the situation, the background, your assessment and your recommendation.
3. Feel uncertain about clinical decisions: Seek input from the supervising physician when youare uncertain about your clinical decisions. Be prepared to present the situation, the background, your assessment and your recommendation.
4. End-of-life care or family/legal discussions: Always call your attending when a patient maydie or there is concern for a medical error or legal issue.
5. Transitions of care: Always call the attending when the patient becomes acutely ill and youare considering transferring to the intensive care unit (or have transferred the patient tothe ICU if patient safety does not allow the call to happen prior to the ICU becoming involved).
6. .Help with system/hierarchy: Call your supervisor if you are not able to advance the care of a patient because of system problems or unresponsiveness of consultants or other providers.

Rev: 08/02/2025