Download DEPARTMENT:_Board of Directors___POLICY

St. Joseph’s Hospital - Phoenix
Medical Staff
Residents and Medical Students Supervision Policy
POLICY:
It is the policy of St. Joseph’s Hospital - Phoenix to specify the mechanisms by which
residents, medical and allied health students are supervised by members of the Medical
Staff.
The management of each patient’s care is the responsibility of a member of the medical
staff with those clinical privileges granted. This policy is intended to guide the activities
of admitting/attending physicians, residents, medical students, allied health practitioners
and hospital personnel in insuring that in-hospital patient care activities in which
residents and students participate are appropriately supervised and documented during
the course of their rotations based in the hospital. This supervision should begin with
the initial contact with the attending physician and the patient, continue through the
daily contact with the patient, and with the attending physician, and be completed when
all the documentation of the hospital stay is collected for the permanent medical record.
All practitioners/students are required to dress appropriately and display
proper identification badges at all times.
DEFINITIONS:
Resident: A resident is a medical doctor (M.D. or D.O.) in a formal residency training
program approved by the Accreditation Council for Graduate Medical Education
(ACGME). An “intern” is a first year resident.
Chief Resident: Chief residents are designated residents with particular leadership
responsibilities. Chief residents may be within their formal training period (“internal
chief resident”). They may also be designated during a post formal residency year.
Both types of chief residents are approved by the Academic Affairs Department, and are
under the same supervision requirements as residents.
Junior Faculty / Instructor: A chief resident who has completed residency training
and is fully eligible for membership on the medical staff in his / her clinical department
may apply for privileges as a faculty member upon the approval of the Program Director
and Department of Academic Affairs. The junior faculty member will be subject to the
same credentialing and qualification requirements and supervisory process as all newly
credentialed members of the medical staff. Their responsibilities as chief resident will be
governed by the job description, Medical Staff Bylaws, and Clinical Department Rules
and Regulations.
Rotating Residents: Resident physicians enrolled in approved ACGME training
programs at other hospitals and medical schools may be permitted to train at St.
Joseph’s Hospital and its associated training programs only if an institutional agreement
is in force between St. Joseph’s Academic Affairs Department and the sponsoring
hospital and medical school, the resident has been approved by the Academic Affairs
Department, and the resident as well as the sponsoring program agree that the rotating
resident is under the same supervision requirements as St. Joseph’s residents.
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Fellow: A fellow is a physician in a specialized training program following formal
completion of initial residency training. Fellows may be in an ACGME approved
fellowship training program, or a non-approved fellowship training program. Both types
of fellowship programs are sponsored and officially designated by St. Joseph’s
Department of Academic Affairs. All fellows are approved by the Academic Affairs
Department, and are under the same supervision requirements as residents.
Medical or Allied Health Student: A medical student or allied health practitioner
student is a student (medical, physician assistant, advanced practice registered nurse) in
an approved training program that has an education affiliation agreement with St.
Joseph’s Hospital - Phoenix.
PROCEDURE:
A. Resident:
1. Appointment: Residents shall not hold medical staff appointment and shall not be entitled to
the rights, privileges, and responsibilities of appointment to the Medical Staff. Residents are
appointed by the Academic Affairs Department through the Medical Education Committee.
2. Licensure: Residents are not formally licensed, but are granted a State of Arizona Training
Permit through the Department of Academic Affairs. If a resident possesses a full unrestricted
Arizona Medical License, this may substitute for the training permit requirement, but the duties,
roles and responsibilities of the licensed resident remain only in the scope of their supervised
training program, and not as an independent licensed medical practitioner. Should a resident
become licensed, that resident is under the same supervision requirements as residents with a
Training Permit.
3. Clinical Care: Residents shall not be granted specific medical staff clinical privileges.
Activities performed by residents shall be under the supervision of a medical staff member.
Clinical activities shall be limited to those of the clinical privileges granted to the supervising
attending physician and agreed upon by the hospital, resident training program and the
sponsoring medical staff member. In an emergency or disaster, residents may act as necessary
until the appropriate supervising physician is present. The job description, provided by the
training program, shall be specific about what the resident can do according to medical
specialty; year(s) in training; level of experience and degree of independence. The Academic
Affairs Department shall maintain a list of all residents currently working at the facility, including
rotating residents.
4. General Responsibilities of Residents: Residents may admit and render patient care in all
hospital services under the supervision of medical staff physicians including:
a. initial and ongoing assessment of patient’s medical, physical, and psychosocial status;
b. perform history and physical;
c. develop assessment and treatment plan;
d. perform patient care management rounds;
e. record progress notes;
f. order tests, examinations, medications, and therapies; including restraints by hospital
protocol;
g. arrange for discharge and after care;
h. write/dictate admission notes, progress notes, procedure notes, and discharge summaries;
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Reviewed: 5/4/2017
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i.
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provide patient education and counseling covering health status, test results, disease
processes, and discharge planning; and
assist in surgery.
Note: All resident care is supervised and the attending physician is ultimately responsible for
care of the patient. Co-signature is as required by hospital policy. The proximity and timing of
the supervision, as well as the specific tasks delegated to the resident physician depend on a
number of factors, including:
a. attending physician has been granted same privileges
b. the level of training (i.e., year in residency) of the resident,
c. the skill and experience of the resident with the particular care situation,
d. the familiarity of the supervising physician with the resident’s abilities, and
e. the acuity of the situation and the degree of risk to the patient.
5. Quality of Care: The quality of care of residents shall be monitored through the medical staff
committee structure and reported to the Medical Executive Committee, Department of
Academic Affairs and its Residency Training Programs, Medical Staff and SJHMC Board.
6. Oversight: The Director of Academic Affairs is responsible for on-site coordination of the St.
Joseph’s residency programs, including all residents, chief residents, fellows, rotating residents
and medical students. The Director reports regularly, but at least annually, to the Medical
Executive Committee regarding the safety and quality of patient care provided by the residents.
Concerns or problems that may arise regarding a resident shall be reported to the Academic
Affairs Medical Director for resolution. If satisfactory resolution is not obtained the issue may
be taken to the Medical Executive Committee.
7. Identification: Residents shall identify themselves as a resident and shall wear name tags
identifying them as such.
8. Participation: Residents may be invited to attend medical staff or hospital committees as
non-voting members. The Chief of Staff will appoint residents to medical staff committees upon
the recommendation of the Department of Academic Affairs.
B. Medical or Allied Health Student:
1. Medical students and allied health students (physician assistant, certified nurse practitioner)
shall not hold medical staff appointment and shall not be entitled to the rights, privileges, and
responsibilities of appointment to the medical staff.
2. Students shall not be granted specific clinical privileges. Activities performed by students shall
be under the supervision of a medical staff member. Co-signature is required on all medical
record entries written by medical students. Clinical activities shall be limited to those of the
clinical privileges granted to the supervising medical staff member and agreed upon by the
hospital, preceptor program and the sponsoring medical staff member.
3. The supervising physician is directly responsible for the actions of the student.
4. Students may do History & Physical examinations at the supervising physician’s discretion.
5. Students are not allowed to examine or treat Emergency Department patients without the
physical presence of the supervising physician or a designated physician within the hospital.
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6. Students shall identify themselves to patients as a medical student under the supervision of the
attending physician. Students shall wear a name badge identifying them as such.
C. Chain of Command: All residents shall be given a copy of the Resident “Chain of Command
Policy” of the Department of Academic Affairs and acknowledge in writing that they have reviewed
it annually.
D. External Regulations: This resident supervision policy does not supercede relevant portions of
the State of Arizona Medical Practice Act (Arizona Revised Statutes), federal CMS regulations on
resident supervision, or individual training program requirements of the ACGME, or other
recognized authorities.
E.
Annual Review: This policy shall be reviewed annually for internal and external compliance with
all mandated regulations as well as quality patient care for St. Joseph’s patient population.
REFERENCES:
SJH Medical Staff Bylaws, Rules and Regulations
AMB/ State of Arizona Medical Practice Act Statutes
ACGME Requirements
Joint Commission Standards
CMS Resident Supervision Regulations
Medical Education Chain of Command Policy
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Revised: MEC 10/27/03; BOARD 10/30/03
Reviewed: 5/4/2017
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Printed: 5/4/2017