cardiac intensive care unit (ccu) and inpatient service ... ccu curriculumfinal.pgy1-3...
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1 REV 08/2020
Cardiac Intensive Care Unit (CCU) and Inpatient Service - KU Internal Medicine Residency Program at University of Kansas Medical Center
Adapted from ABIM Developmental Milestones PGY1 – standard text
PGY2 – standard and italicized text PGY3, PGY4, PGY5 – standard, italicized and bold italicized text
Director(s): David Wilson, M.D., Jared Kvapil, M.D. Duration: 1-3 weeks based on block schedule arrangement Supervision: Attending Responsible for the CCU and Cardiology Inpatient Service Facility: University of Kansas Medical Center Required Didactics:
1. Core and Case Conferences - Monday, Tuesday, Thursday, and Friday at 12:00 PM
Location Varies Daily 2. Grand Rounds – Wednesday at 12:00 PM
School of Nursing Auditorium 3. Patient Safety Conference – Every Other Month - Sep, Nov, Jan, Mar, May at 12:00 PM
Clendening Auditorium 4. Clinicopathologic Conference – Quarterly - Sep, Dec, Mar, Jun at 12:00 PM
Clendening Auditorium Educational Purpose: Residents are required to complete at least one CCU rotation because of the invaluable experience it offers in the care of acute cardiac illness. Cardiac disease is the most-represented subject area on the ABIM examination, and it encompasses the most often encountered diagnoses in the general practice of Internal Medicine. During the CCU rotation, residents will gain competency in cardiac patient care and medical knowledge by learning to manage patients presenting with acute coronary syndromes and arrhythmias, as well as less common disorders such as complications of cardiac transplant. Educational Methods: Direct observation of patient care and bedside teaching occur in the setting of daily ICU and
inpatient rounds with the cardiology attending. Residents evaluate and treat patients both in the
capacity of new admissions and follow-up. The supervising attending reviews and critiques the
resident’s interpretation of diagnostic studies and formulation of assessments and plans.
Residents attend didactic sessions as above. Residents additionally have the opportunity to be
present for invasive and non-invasive cardiac procedures such as echo cardiograms, nuclear
stress tests, device (pacemakers and cardioverter defibrillators) insertion, and cardiac
catheterization. Recommended educational resources for this rotation include the following:
1. Zipes, D., Braunwald’s Heart Disease: A textbook of Cardiovascular Medicine, 11th Edition. 2018
2. Murphy, JG., Mayo Clinic Cardiology: Concise Textbook, 4nd Edition. 2012.
3. Moscuccil, M. Grossman & Baim's Cardiac Catheterization, Angiography, and Intervention, 8th Edition. Philadelphia, Lippincott, Williams and Wilkins. 2012.
4. Topol EJ., Textbook of Interventional Cardiology, 7th Edition. 2015.
5. Zipes DP, Jalife J., Clinical Electrophysiology: From the Cell to the Bedside. 7th edition, 2017.
6. Armstrong, W.F., Ryan, T., Feigenbaum’s Echocardiography, 8th edition 2018
7. Goldberger, A. L. Goldberger’s Clinical Electrocardiography: A Simplified Approach. 9th Edition 2017.
8. O’Keefe, J.H., The Complete Guide to ECGs 4rd edition 2016
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9. www.acc.org
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1
a. Awareness of indications, contraindications, risks and benefits of common ICU invasive procedures
b. Appropriately perform invasive procedures under supervision of the attending staff, fellow, or supervising resident
Cardiac Intensive Care Unit (CCU) Service-KU
CCU OVERALL GOALS and OBJECTIVES OVERALL COMPETENCY PROGRESSION BY CORE COMPETENCY AND PGY LEVEL
(Adapted from ABIM Developmental Milestones)
CORE COMPETENCY: PATIENT CARE PGY LEVEL GOAL History and Data Gathering
OBJECTIVES
1
a. Acquire accurate and relevant history from the patient in an efficiently customized, prioritized, and hypothesis driven fashion
b. Seek and obtain appropriate, verified, and prioritized data from secondary sources (e.g. family, records, pharmacy)
2
c. Obtain relevant historical subtleties that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient
3 4 5
d. Role model gathering subtle and reliable information from the patient for junior members of the healthcare team
PGY LEVEL GOAL Performing a Physical Examination OBJECTIVES
1
a. Perform an accurate physical examination that is appropriately targeted to the patient's complaints and medical conditions. Identify pertinent abnormalities using common maneuvers
b. Accurately track important changes in the physical examination over time in the ICU or inpatient setting
2
c. Demonstrate and teach how to elicit important physical findings for junior members of the healthcare team
3 4 5
d. Routinely identify subtle or unusual physical findings that may influence clinical decision making, using advanced maneuvers where applicable
PGY LEVEL GOAL Clinical Reasoning
OBJECTIVES
1
a. Synthesize all available data, including interview, physical examination, and preliminary laboratory data, to define each patient’s central clinical problem
b. Develop prioritized differential diagnoses, evidence-based diagnostic and therapeutic plan for common ICU conditions
2
c. Modify differential diagnosis and care plan based upon clinical course and data as appropriate
3 4 5
d. Recognize disease presentations that deviate from common patterns and that require complex decision making
PGY LEVEL GOAL Invasive Procedures OBJECTIVES
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2
c. Appropriately perform invasive procedures and provide post-procedure management for common procedures
PGY LEVEL GOAL Patient Management OBJECTIVES
1
a. Recognize situations with a need for urgent or emergent medical care including life threatening conditions
b. Recognize when to seek additional guidance c. Provide appropriate preventive care and teach patient regarding self-care in the ICU or
inpatient setting d. Initiate management and stabilize patients with emergent medical conditions
3 4 5
e. Manage patients with conditions that require intensive care f. Manage complex or rare medical conditions g. Customize care in the context of the patient’s preferences and overall health
Evaluation Methods Faculty evaluation, EPA, Direct Observation
PGY LEVEL GOAL Diagnostic Tests OBJECTIVES
1
a. Make appropriate clinical decisions based upon the results of common diagnostic testing, including but not limited to routine blood chemistries, hematologic studies, coagulation tests, arterial blood gases, ECG, chest radiographs, pulmonary function tests, urinalysis and other body fluids
2
b. Make appropriate clinical decision based upon the results of more advanced diagnostic tests
CORE COMPETENCY: MEDICAL KNOWLEDGE PGY LEVEL GOAL Core Content Knowledge
OBJECTIVES
1
a. Understand the relevant pathophysiology and basic science for common inpatient and ICU conditions
2
b. Demonstrate sufficient knowledge to diagnose and treat undifferentiated and emergent conditions
c. Demonstrate sufficient knowledge to identify and treat medical conditions that require intensive care
3 4 5
d. Demonstrate sufficient knowledge to evaluate complex or rare medical conditions and multiple coexistent conditions
e. Understand the relevant pathophysiology and basic science for uncommon or complex medical conditions
f. Demonstrate sufficient knowledge of socio-behavioral sciences including but not limited to health care economics, medical ethics, and medical education
PGY LEVEL GOAL Diagnostic Tests OBJECTIVES
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Evaluation Methods Faculty evaluation, ITE, EPA, Case Conference evaluation, Direct Observation
1
a. Understand indications for and basic interpretation of common diagnostic testing, including but not limited to routine blood chemistries, hematologic studies, coagulation tests, arterial blood gases, ECG, chest radiographs, pulmonary function tests, urinalysis and other body fluids
2
b. Understand indications for and has basic skills in interpreting more advanced diagnostic tests
c. Understand prior probability and test performance characteristics
CORE COMPETENCY: PRACTICEBASED LEARNING AND IMPROVEMENT PGY LEVEL GOAL Ask Answerable Questions for Emerging Information Needs
OBJECTIVES
1
a. Identify learning needs (clinical questions) as they emerge in patient care activities
2
b. Classify and precisely articulate clinical questions c. Develop a system to track, pursue, and reflect on clinical questions
PGY LEVEL GOAL Acquires the Best Advice OBJECTIVES
1
a. Access medical information resources to answer clinical questions and library resources to support decision making
2
b. Effectively and efficiently search NLM database for original clinical research articles c. Effectively and efficiently search evidence-based summary medical information
resources
3 4 5
d. Appraise the quality of medical information resources and select among them based on the characteristics of the clinical question
PGY LEVEL GOAL Appraises the Evidence for Validity and Usefulness OBJECTIVES
1
a. With assistance, appraise study design, conduct and statistical analysis in clinical research papers
b. With assistance, appraise clinical guideline recommendations for bias
3 4 5
c. With assistance, appraise study design, conduct, and statistical analysis in clinical research papers
d. Independently, appraise clinical guideline recommendations for bias and cost-benefit considerations
PGY LEVEL GOAL Applies the evidence to decision-making for individual patients OBJECTIVES
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Evaluation Methods Faculty Evaluation, Patient Safety Conference evaluation, Case Conference evaluation
1
a. Determine if clinical evidence can be generalized to an individual patient
3 4 5
b. Customize clinical evidence for an individual patient c. Communicate risks and benefits of alternatives to patients d. Integrate clinical evidence, clinical context, and patient preferences into
decision-making
PGY LEVEL GOAL Improves Via Feedback OBJECTIVES
1
a. Respond welcomingly and productively to feedback from all members of the health care team including faculty, peer residents, students, nurses, allied health workers, patients and their advocates
b. Actively seek feedback from all members of the health care team
2
c. Calibrate self-assessment with feedback and other external data d. Reflect on feedback in developing plans for improvement
PGY LEVEL GOAL Improves via self-assessment OBJECTIVES
2
a. Maintain awareness of the situation in the moment and respond to meet situational needs
3 4 5
b. Reflect (in action) when surprised, applies new insights to future clinical scenarios, and reflects (on action) back on the process
PGY LEVEL GOAL Participate in education of all members of the health care team OBJECTIVES
P1
a. Actively participate in teaching conferences
2
b. Integrate teaching, feedback, and evaluation with supervision of interns’ and students’ patient care
3 4 5
c. Take a leadership role in the education of all members of the health care team.
CORE COMPETENCY: INTERPERSONAL & COMMUNICATION SKILLS PGY LEVEL GOAL Communicate effectively
OBJECTIVES
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1
a. Provide timely and comprehensive verbal and written communication to patients/advocates
b. Effectively use verbal and non-verbal skills to create rapport with patients/families c. Use communication skills to build a therapeutic relationship
2
d. Engage patients/advocates in shared decision-making for uncomplicated diagnostic and therapeutic scenarios
e. Utilize patient-centered education strategies
3 4 5
f. Engage patients/advocates in shared decision-making for difficult, ambiguous or controversial scenarios
g. Appropriately counsel patients about the risks and benefits of tests and procedures highlighting cost awareness and resource allocation when appropriate
h. Role model effective communication skills in challenging situations when appropriate
PGY LEVEL GOAL Intercultural sensitivity OBJECTIVES
1
a. Effectively use an interpreter to engage patients in the clinical setting including patient education when appropriate
b. Demonstrate sensitivity to differences in patients including but not limited to race, culture, gender, sexual orientation, socioeconomic status, literacy, and religious beliefs
3 4 5
c. Actively seek to understand patient differences and views and reflects this in respectful communication and shared decision-making with the patient and the healthcare team
PGY LEVEL GOAL Transitions of Care
OBJECTIVES
1
a. Effectively communicate with other caregivers in order to maintain appropriate continuity during transitions of care
2
b. Role model and teach effective communication with next caregivers during transitions of care
PGY LEVEL GOAL Interprofessional team OBJECTIVES
1
a. Deliver appropriate, succinct, hypothesis-driven oral presentations b. Effectively communicate plan of care to all members of the health care team
3 c. Engage in collaborative communication with all members of the health care team
PGY LEVEL GOAL Consultation OBJECTIVES
1
a. Request consultative services in an effective manner b. Clearly communicate the role of consultant to the patient, in support of the primary care
relationship
3 c. Communicate consultative recommendations to the referring team in an effective
manner
PGY LEVEL GOAL Health Records OBJECTIVES
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Evaluation Methods Faculty Evaluation, 360 Evaluations, Patient Safety Conference Evaluation, Case Conference evaluation
1
a. Provide legible, accurate, complete, and timely written communication that is congruent with medical standards
2
b. Ensure succinct, relevant, and patient-specific written communication
CORE COMPETENCY: PROFESSIONALISM PGY LEVEL GOAL Adhere to basic ethical principles
OBJECTIVES
1
a. Document and report clinical information truthfully b. Follow formal policies c. Accept personal errors and honestly acknowledge them
3 4 5
d. Uphold ethical expectations of research and scholarly activity
PGY LEVEL GOAL Demonstrate compassion and respect to patients OBJECTIVES
1
a. Demonstrate empathy and compassion to all patients b. Demonstrate a commitment to relieve pain and suffering
2
c. Provide support (physical, psychological, social and spiritual) for dying patients and their families
d. Provide leadership for a team that respects patient dignity and autonomy
PGY LEVEL GOAL Provide timely, constructive feedback to colleagues OBJECTIVES
1
a. Communicate constructive feedback to other members of the health care team\
2
b. Recognize, respond to and report impairment in colleagues or substandard care via peer review process
PGY LEVEL GOAL Maintain Accessibility OBJECTIVES
1
a. Responsibilities including but not limited to calls and pages b. Carry out timely interactions with colleagues, patients and their designated caregivers
PGY LEVEL GOAL Recognize conflicts of interest OBJECTIVES
1
a. Recognize and manage obvious conflicts of interest, such as caring for family members and professional associates as patients
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2
b. Maintain ethical relationships with industry c. Recognize and manage subtler conflicts of interest
PGY LEVEL GOAL Demonstrate personal accountability OBJECTIVES
1
a. Dress and behave appropriately. Scrubs are only to be worn on call and underneath a white lab coat
b. Maintain appropriate professional relationships with patients, families and staff c. Ensure prompt completion of clinical, administrative, and curricular tasks d. Recognize and address personal, psychological, and physical limitations that may
affect professional performance e. Recognize the scope of his/her abilities and ask for supervision and assistance
appropriately
3 4 5
f. Serve as a professional role model for more junior colleagues (e.g., medical students, interns)
g. Recognize the need to assist colleagues in the provision of duties
PGY LEVEL GOAL Practice individual patient advocacy OBJECTIVES
1
a. Recognize when it is necessary to advocate for individual patient needs
3 4 5
b. Effectively advocate for individual patient needs
PGY LEVEL GOAL Comply with public health policies OBJECTIVES
2
a. Recognize and take responsibility for situations where public health supersedes individual health (e.g. reportable infectious diseases)
PGY LEVEL GOAL Respect the dignity, culture, beliefs, values and opinions or the patient OBJECTIVES
1
a. Treat patients with dignity, civility and respect, regardless of race, culture, gender, ethnicity, age or socioeconomic status
3 4 5
b. Recognize and manage conflict when patient values differ from their own
PGY LEVEL GOAL Confidentiality OBJECTIVES
1
a. Maintain patient confidentiality
2
b. Educate and hold others accountable for patient confidentiality
PGY LEVEL GOAL Recognize and address disparities in health care OBJECTIVES
1
a. Recognize that disparities exist in health care among populations and that they may impact care of the patient
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Evaluation Methods Faculty Evaluation, 360 Evaluations, EPA, Patient Safety Conference Evaluation, Case Conference evaluation
3 4 5
b. Embrace physicians’ role in assisting the public and policy makers in understanding and addressing causes of disparity in disease and suffering
c. Advocates for appropriate allocation of limited health care resources.
CORE COMPETENCY: SYSTEMS BASED PRACTICE PGY LEVEL GOAL Works effectively within multiple health delivery systems
OBJECTIVES
1
a. Understand unique roles and services provided by local health care delivery systems
2
b. Manage and coordinate care and care transitions across multiple delivery systems, including ambulatory, subacute, acute, rehabilitation, and skilled nursing.
3 4 5
c. Negotiate patient-centered care among multiple care providers.
PGY LEVEL GOAL Works effectively within an interprofessional team OBJECTIVES
1
a. Appreciate roles of a variety of health care providers, including, but not limited to, consultants, therapists, nurses, home care workers, pharmacists, and social workers.
b. Work effectively as a member within the interprofessional team to ensure safe patient care.
c. Consider alternative solutions provided by other teammates
3 4 5
d. Demonstrate how to manage the team by utilizing the skills and coordinating the activities of interprofessional team members
PGY LEVEL GOAL Recognizes system error and advocates for system improvement OBJECTIVES
1
a. Recognize health system forces that increase the risk for error including barriers to optimal patient care
b. Identify, reflect upon, and learn from critical incidents such as near misses and preventable medical errors
2
c. Dialogue with care team members to identify risk for and prevention of medical error d. Understand mechanisms for analysis and correction of systems errors
3 4 5
e. Demonstrate ability to understand and engage in a system level quality improvement intervention.
f. Partner with other healthcare professionals to identify, propose improvement opportunities within the system.
PGY LEVEL GOAL Identify forces that impact the cost of health care and advocates for cost-effective care
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Evaluation Methods Faculty Evaluation
OBJECTIVES 1
a. Reflect awareness of common socio-economic barriers that impact patient care. b. Understand how cost-benefit analysis is applied to patient care (i.e. via principles of
screening tests and the development of clinical guidelines)
2
c. Identify the role of various health care stakeholders including providers, suppliers, financiers, purchasers and consumers and their varied impact on the cost of and access to health care.
d. Understand coding and reimbursement principles
PGY LEVEL GOAL Practices cost-effective care OBJECTIVES
1
a. Identify costs for common diagnostic or therapeutic tests b. Minimize unnecessary care including tests, procedures, therapies and excessive
inpatient and ICU length of stay
2
c. Demonstrate the incorporation of cost-awareness principles into standard clinical judgments and decision-making
3 4 5
d. Demonstrate the incorporation of cost-awareness principles into complex clinical scenarios
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PGY LEVEL GOAL Identify forces that impact the cost of health care and advocates for cost-effective care OBJECTIVES
EVALUATION METHODS P
GY
1
e. Reflect awareness of common socio-economic barriers that impact patient care.
f. Understand how cost-benefit analysis is applied to patient care (i.e. via principles of screening tests and the development of clinical guidelines)
PG
Y2
g. Identify the role of various health care stakeholders including providers, suppliers, financiers, purchasers and consumers and their varied impact on the cost of and access to health care.
h. Understand coding and reimbursement principles
PGY LEVEL GOAL Practices cost-effective care OBJECTIVES
EVALUATION METHODS
PG
Y1
e. Identify costs for common diagnostic or therapeutic tests
f. Minimize unnecessary care including tests, procedures, therapies and excessive inpatient and ICU length of stay
PG
Y2
g. Demonstrate the incorporation of cost-awareness principles into standard clinical judgments and decision-making
PGY 3 4 5
h. Demonstrate the incorporation of cost-awareness principles into complex clinical scenarios
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CARDIAC INTENSIVE CARE UNIT (CCU) SERVICE-KU SERVICE SPECIFIC GOALS and OBJECTIVES
ADDITIONAL COMPETENCY EXPECTATIONS SPECIFIC TO INTENSIVE CARE UNIT (TICU/MICU) SERVICE
CORE COMPETENCY: MEDICAL KNOWLEDGE
GOAL Develop Core Content Knowledge for common inpatient and ICU medical conditions including but not limited to:
1. Aortic Aneurysm and Dissection 2. Arrhythmia
1. Atrial Fibrillation/Flutter 2. Heart Block – Various Degrees of Conduction Abnormalities 3. Paroxysmal Supraventricular Tachycardia 4. Premature Atrial and Ventricular Contractions 5. QT Prolongation Syndromes 6. Wolff-Parkinson-White Conduction
3. Acute Coronary Syndrome 1. Invasive Management 2. Non-Invasive Management
4. Cardiomyopathies 1. Acute and Chronic Congestive Heart Failure 2. Compensated and Decompensated Congestive Heart Failure 3. Hypertrophic Obstructive Cardiomyopathy 4. Toxin Mediated
5. Congenital Heart Disease 1. Atrial Septal Defect 2. Patent Ductus Arteriosus 3. Marfan Syndrome 4. Valvular Heart Disease
1. Mitral Valve Prolapse 2. Bicuspid Aortic Valve
5. Ventricular Septal Defect 6. Coronary Artery Disease
1. Acute Coronary Syndromes 2. Risk Factors and Preventative Measures 3. Chronic Medical Management
7. Chest Pain 8. Device Implantation – Indications, Management
1. Cardioverter Defibrillators 2. Pacemakers
9. Hemodynamic Monitoring 10. Hyperlipidemia 11. Murmurs
1. Physiologic/ Innocent 2. Pathologic
12. Pericarditis 13. Peripheral Artery Disease 14. Pre-, Peri-, and Post-operative Cardiac Evaluation, Testing, and Management 15. Pregnancy and Cardiac Disease 16. Prosthetic Heart Valves 17. Valvular Heart Disease
1. Aortic Regurgitation 2. Aortic Stenosis 3. Mitral Regurgitation 4. Mitral Stenosis
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Evaluation Methods Faculty evaluation, ITE, Case Conference evaluation, Direct Observation
PGY LEVEL OBJECTIVES
PG
Y1
a. Understand the relevant pathophysiology and basic understanding necessary for
initial diagnosis and treatment of common inpatient and ICU conditions
PG
Y2
b. Demonstrate sufficient knowledge to diagnose and treat undifferentiated and
emergent conditions c. Demonstrate sufficient knowledge to identify and treat medical conditions that require
intensive care
PGY 3 4 5
d. Demonstrate sufficient knowledge to evaluate complex or rare medical conditions and multiple coexistent conditions
e. Understand the relevant pathophysiology and basic science for uncommon or complex medical conditions
f. Demonstrate sufficient knowledge of socio-behavioral sciences including but not limited to health care economics, medical ethics, and medical education
CORE COMPETENCY: PATIENT CARE
GOAL Develop increasing knowledge and ability to perform the following Invasive Procedures: 1. Nuclear Cardiac Testing 2. Cardiac Catheterization with and without percutaneous coronary intervention 3. Electrophysiology Testing 4. Pacemakers and Cardioverter Defibrillators 5. Invasive Hemodynamic Monitoring and Support
PGY LEVEL OBJECTIVES
1
a. Awareness of indications, contraindications, risks and benefits of common ICU invasive procedures
b. Appropriately perform invasive procedures under supervision of the attending staff, fellow, or supervising resident
2
c. Appropriately perform invasive procedures and provide post-procedure management for common procedures
GOAL Develop increasing knowledge and / or ability to perform the following Diagnostic Tests 1. Echocardiography 2. Electrocardiography 3. Holter Monitoring and Event Recorder Monitoring 4. Nuclear Cardiac Testing 5. Stress Testing 6. Telemetry
PGY LEVEL OBJECTIVES
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1
a. Make appropriate clinical decisions based upon the results of common diagnostic testing, including but not limited to routine blood chemistries, hematologic studies, coagulation tests, arterial blood gases, ECG, chest radiographs, pulmonary function tests, urinalysis and other body fluids
2
c. Make appropriate clinical decision based upon the results of more advanced diagnostic tests
Evaluation Methods Faculty evaluation, EPA, Direct Observation
Evaluation Methods Faculty Evaluation, Patient Safety Conference evaluation, Case Conference evaluation
CORE COMPETENCY: PRACTICEBASED LEARNING AND IMPROVEMENT
GOAL Participate in education of all members of the health care team Required Didactics:
1. Core and Case Conferences - Monday, Tuesday, Thursday, and Friday at 12:00 PM
Location Varies Daily 2. Grand Rounds – Wednesday at 12:00 PM
School of Nursing Auditorium 3. Patient Safety Conference – Every Other Month - Sep, Nov, Jan, Mar, May at
12:00 PM
Clendening Auditorium 4. Clinicopathologic Conference – Quarterly - Sep, Dec, Mar, Jun at 12:00 PM
Clendening Auditorium 5. Cardiology Conference – Wednesdays at 7:00 AM
5th Floor Conference Room - Heart Hospital PGY LEVEL OBJECTIVES
1
a. Actively participate in teaching conferences
2
b. Integrate teaching, feedback, and evaluation with supervision of interns’ and students’ patient care
3 4 5
c. Take a leadership role in the education of all members of the health care team.
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GMEC Resident Supervision
A. Supervision of Residents
Each patient must have an identifiable, appropriately credentialed and privileged attending physician (or licensed independent practitioner as specified by each Review Committee) who is responsible and accountable for that patient’s care. VI.A.2.a).(1)
This information must be available to residents, faculty members, other members of the health care team, and patients. VI.A.2.a).(1)(a)
o Inpatient: Patient information sheet included in the admission packet and listed on the “white board” in each patient room
o Outpatient: Provided during introduction verbally by residents and/or faculty
Residents and faculty members must inform patients of their respective roles in each patient’s care when providing direct patient care. VI.A.2.a).(1)(b)
The program must demonstrate that the appropriate level of supervision in place for all residents is 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. VI.A.2.b).(1)
B. Methods of Supervision.
Supervision may be exercised through a variety of methods.
For many aspects of patient care, the supervising physician may be a more advanced resident or fellow.
Other portions of care provided by the resident can be adequately supervised by the appropriate availability of the supervising faculty member, fellow or senior resident physician, and either on site or by means of telecommunication technology. Some activities require the physical presence of the supervising faculty member. In some circumstances, supervision may include post-hoc review of resident delivered care with feedback. VI.A.2.b)
The program must demonstrate that the appropriate level of supervision in place for all residents is 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. VI.A.2.b).(1)
The Review Committee may specify which activities require different levels of supervision. VI.A.2.b).(1)
The program must define when physical presence of a supervising physician is required. (Core) VI.A.2.b).(2)
C. Levels of Supervision Defined
To promote appropriate resident supervision while providing for graded authority and responsibility, the program must use the following classification of supervision: Direct Supervision:
Direct A: The supervising physician is physically present with the resident during the key portions of the patient interaction or, VI.A.2.c).(1).(a) PGY-1 residents must initially be supervised directly only as described in VI.A.2.c).(1).(a) [The Review Committee may describe the conditions under which PGY-1 residents progress to be supervised indirectly]
Direct B: 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. [The Review
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Committee must further specify if VI.A.2.c).(1).(b) is permitted] [The Review Committee will choose to require either VI.A.2.c).(1).(a), or both VI.A.2.c).(1).(a) and VI.A.2.c).(1).(b)] VI.A.2.c).(1).(b)
Indirect Supervision: The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision. VI.A.2.c).(2)
Oversight:
The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered. VI.A.2.c).(3)
The privilege of progressive authority and responsibility, conditional independence, and as supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members. VI.A.2.d)
Per
Pro
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RR
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Each patient must have an identifiable and appropriately-credentialed and privileged attending physician (or RRC APPROVED LICENSED INDEPENDENT PRACTITIONER SUPERVISOR) who is responsible and accountable for the patients care, and this information must be available to the residents, faculty members, other members of the health care team and patients. (PR VI.A.2.a (1)
Information regarding licensure for attending physicians is available via a publicly available database: http://docfinder.docboard.org/ks/df/kssearch.htm Licensure data on resident physicians is kept up to date in the University of Kansas Health System GME Office.
Residents and Faculty members must inform each patient of their respective roles in patient care, when providing direct patient care. VI.A.2.a). (1).(b.)
This information must be available to residents, faculty members, other members of the health care team, and patients.
Inpatient: Patient information sheet included in the admission packet and listed on the “white board” in each patient room. Provided during introduction verbally by residents and/or faculty.
Outpatient: Communicated to patient at time of appointing scheduling. Provided during introduction verbally by residents and/or faculty.
PGY-1 residents must initially be supervised directly only as described in VI.A.2.c).(1).(a) [The Review Committee may describe the conditions under which PGY-1 residents progress to be supervised indirectly] VI.A.2.c).(1).(a).(i)
PGY-1 residents are supervised, either directly or indirectly with direct supervision immediately available on site, by PGY-2 or PGY-3 residents or staff members on all rotations, including night float, at all training sites. At all sites, during daytime inpatient, consult, and outpatient rotations, supervision is direct and occurs by an attending physician as well as a senior resident and/or fellow in many circumstances. On night float rotation at KU Hospital, a senior resident and a hospitalist faculty attending are present on location to immediately provide direct supervision. On night float rotation at Kansas City VA Hospital, a senior resident is present on location to immediately provide direct supervision and a faculty attending is immediately available by pager
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and is available to provide Direct Supervision. Residents are not responsible for nighttime coverage at the Leavenworth VA Hospital.
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. (PR VI.A.2.d).(1,2,3)
The program has adapted the American Board of Internal Medicine’s Milestones of Competency to delineate our overall and rotational goals and objectives. Our evaluation system provides data on the ACGME reporting milestones. This data along with review of the resident’s portfolio of work allows the Program Director and faculty members to make determinations on a resident’s ability to gain progressive authority and responsibility. 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. Senior residents or fellows serve in a supervisory role to junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow
RARE CIRCUMSTANANCES WHEN RESIDENTS may elect to stay or return to the clinical site: (PR VI.F.4.a.)
In rare circumstances, after handing off all other responsibilities, a resident, on their own
initiative, may elect to remain or return to the clinical site in the following circumstances:
to continue to provide care to a single severely ill or unstable patient;
to attend to humanistic attention to the needs of a patient or family; or,
to attend unique educational events.
The program monitors circumstances in which residents stay beyond scheduled periods of duty
through the institutional work hours monitoring system in MedHub. The program leadership
reviews the resident clinical work and education report weekly, and residents are instructed to
enter a comment in their work hours report indicating the reason for their work hours violation.
In addition, the chief residents contact all residents with reported work hours violations to inquire
about the cause and impact of the violation. This data is reviewed and discussed during weekly
program leadership meeting, and trends are carefully sought and addressed.
DEFINED MAXIMUM NUMBER OF CONSECUTIVE WEEKS OF NIGHT FLOAT AND MAXIMUM NUMBER OF MONTHS PER YEAR OF IN-HOUSE NIGHT FLOAT (PR VI.F. 6.)
Maximum Frequency of In-House Night Float
Residents must not be scheduled for more than six consecutive nights of night float.
Residents must not be assigned more than two months of night float during any year of training, or more than four months of night float over the three years of residency training. Residents must not be assigned more than one month of consecutive night float.)
19 REV 08/2020
Program-specific guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty (PR VI.A.2.e)
1. Admission to Hospital 2. Transfer of patient to a higher level of care 3. Clinical deterioration, especially if unexpected 4. End-of-life decisions 5. Change in code status 6. Red Events 7. Change in plan of care, unplanned emergent surgery or planned procedure that does not
occur 8. Procedural complication 9. Unexpected patient death
PGY 1
LEVEL of SUPERVISION ACTIVITIES /PROCEDURES (as defined by RRC & Program)
DIRECT A ACLS
Arterial blood draw
Arterial line
20 REV 08/2020
Arthrocentesis
Bone marrow aspiration
Bone marrow biopsy
Bronchoscopy
Cardioversion
Chest tube placement
Intubation, elective
Intubation, emergent
Laryngeal mask airway
Lumbar puncture
Nasogastric tube placement
Pap smear (until at least one performed)
Paracentesis
Thoracentesis
Ultrasound for central line placement.
DIRECT B N/A
INDIRECT Electrocardiogram interpretation (preliminary interpretation)
Peripheral IV
Radiology interpretation (preliminary interpretation)
Venous blood draw.
All OTHER RESIDENTS
LEVEL of SUPERVISION ACTIVITIES /PROCEDURES (as defined by RRC & Program)
DIRECT A Bone marrow aspiration
Bone marrow biopsy
Bronchoscopy
Cardioversion
21 REV 08/2020
Chest tube placement
Intubation, elective
Intubation, emergent
Laryngeal mask airway
DIRECT B N/A
INDIRECT ACLS
Electrocardiogram interpretation
Incision and drainage of an abscess
Nasogastric tube placement
Pap smear
Peripheral IV
Radiology interpretation
Venous blood draw
Each of the procedures below can be performed with Indirect
supervision with direct supervision immediately available provided
that quantitative and qualitative assessment metrics have been met
AND that procedural certification supervision requirements have
been updated in Medhub by the program director:
Arterial blood draw
Arterial line placement
Arthrocentesis
Central venous line placement
Lumbar puncture
Paracentesis
Thoracentesis
Ultrasound for central line placement
OVERSIGHT N/A
22 REV 08/2020
GMEC-EC APPROVAL 5/27/11
GMEC APPROVAL 6/6/11, 06/05/17, 8/3/20
Modified 6/20/11, 5/2/17, 7/16/20