1. Supervision Sunny G. Yoder Director, Graduate Medical Education AAMC VCU Conference, December 7, 2010

2. NOT JUST FOR DOCTORS: When you get anomalous data in a high-stakes environment, what do you do? When do you call?

3. Deepwater Horizon, April 20, 2010

4. Concern in the Policy Sphere IOM, “Crossing the Quality Chasm”, 2001- Safety is a system quality that patients should expect IOM “To Err is Human”, 2000 - 44,000 to 98,000 hospital deaths attributable to medical errors

5. Concern in the Policy Sphere IOM “Resident Duty Hours”, 2009 -Supervision is key to balancing educational needs of residents and safety of patients MedPAC Report, June 2010 -Redundant, team-based care; tie Medicare $ to competencies needed in 21 st century medicine

6. Public Concern – July 1 st Effect - Public Release Date: June 2, 2010 - J Gen Intern Med. 2010 August; 25(8): 774–779

7. When news spreads like wildfire… June 2, 2010

8. June 29, 2010 June 3, 2010 July 15, 2010

9. June 21, 2010

10. July 5, 2010

11. July 1 st Effect Hits Legal Websites Too! June 4, 2010 July 17, 2010

12. ACGME 2010 Standards – A Response to Concerns Objectives: the safety and quality of care of the patients under the care of residents today the safety and quality of care of the patients under the care of our graduates in their future practice the provision of a humanistic educational environment

13. ACGME 2010 Standards Far more explicit about supervision than in the past Default is ‘not ready’ – especially for PGY1 - resident must demonstrate competence Supervision by more senior residents is recognized

14. JCAHO Addresses Supervision Too “The medical staff must have a defined process under which each resident is supervised in his or her patient care responsibilities by a LIP with appropriate privileges.”

15. AAMC Annual Meeting Sessions Sponsored by Group on Resident Affairs Principles and tools SUPERVISION: STORIES FROM THE FIELD Mark Wilson, M.D., University of Iowa https://www.aamc.org/download/161 546/data/plenary_2_wilson.pdf

16. From Iowa Supervision is the Next GME Frontier. To change the culture, we have to make it a conscious pursuit.

17. From Iowa Include assessment of supervisory practices as specific component of internal reviews Grade how well programs address: Patient safety Graduated responsibility Measurable objectives

18. From Iowa Establish that direct supervision is the default mode until milestone capability is ‘checked off’ Develop a ‘supervision curriculum’ that drives faculty & resident development Devise ways to assess how residents can demonstrate: -‘when they need to ask for help’ -ability to anticipate potential patient problems -ability to acknowledge/manage uncertainty

19. AAMC Annual Meeting Sessions Sponsored by Group on Resident Affairs Principles and tools SUPERVISION: STORIES FROM THE FIELD Vineet Arora, M.D., University of Chicago https://www.aamc.org/download/161 544/data/plenary_2_arora.pdf

20. From Southside Chicago The barriers to good supervision are many; guidelines help.

21. From Southside Chicago

22. AAMC Annual Meeting Sessions Sponsored by Group on Resident Affairs MONITORING COMPLIANCE: MEASURES AND METHODS Linda M. Famiglio, M.D. Chief Academic Officer Academic Affairs, Geisinger Health System Associate Dean, Temple University School of Medicine https://www.aamc.org/download/161 556/data/plenary_3_famiglio.pdf

23. From Rural Pennsylvania What data do you have to respond when the Joint Commission or the ACGME asks how do you know that the residents are supervised in caring for patients?

24. From Rural Pennsylvania Time lapse between resident and attending H&P Medical reconciliation at time of transfer And reflect on failures - RCA’s, Sentinel events – hardwire communications to quality committee Inappropriate orders or suboptimal orders, e.g., Number of contrast CT’s ordered by residents and later canceled MONITOR…

25. Is key to safe, effective, timely care – public and policymakers want assurance that trainees are effectively supervised. Is key to resident education and assessment of readiness for unsupervised practice. Is a competency for which both attendings and residents need to be prepared. Can be observed directly and also assessed from patient care processes and outcomes. Safety is an issue in other enterprises-what can we learn? Must ensure the resident is ready for independent practice. Concluding Observations SUPERVISION…

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