Supervision of Post-graduate Trainees

Effective Date: 12/1/99   
Original Date:           12/1/99     
Reviewed/Revised:     2/2/09, 2/2/10                         
Next Review Date:  2/2/11 

Number:  9200-211

Supervision of Patient Care Provided by Post-graduate Trainees (Residents)

1.0 Purpose

1.1               In accordance with NYS DOH 405.4, the purpose of this policy is to “set forth the principles governing medical practice by postgraduate trainees, including guidelines on circumstances requiring supervision and consultation”.

2.0 Procedure

2.1               Postgraduate trainees may qualify for appointment to the Graduate Staff provided they meet the eligibility criteria stipulated in the general “ Resident Eligibility and Selection Process” (GME policy and procedure) and the eligibility criteria stipulated in “Eligibility and Selection Process” Policy for the individual program to which they are applying.

2.2               Postgraduate trainees may provide patient care services only (1) as part of one of New York Hospital Queens’ sponsored training programs or (2) as part of a training program with which NYHQ has an affiliation or participating agreement (rotating postgraduate trainees).

2.3               Participating agreements must include the term of the rotation and the departmental faculty who will be responsible for the rotating postgraduate trainee’s supervision.

2.4               All postgraduate trainees including rotating trainees will be credentialed according to the “Graduate Staff Credentialing Policy and Procedure”.

2.5               Prior to being permitted to provide patient care services, postgraduate trainees must be appointed to the Graduate Staff by the Board of Trustees at the recommendation of the Medical Board.

2.6               Only physicians, podiatrists or dentists credentialed by the Medical Board to provide patient care in their respective specialty (Board certified or board eligible) may supervise postgraduate trainees in medicine, pediatrics, obstetrics, radiation oncology, emergency medicine, podiatry, dental medicine, and surgery.

2.7               For postgraduate trainees in obstetrics, a supervising attending obstetrician, credentialed and granted privileges by the Medical Board, shall be physically present in the hospital 24 hours per day, seven days a week.

2.8               For postgraduate trainees in Emergency Medicine, a supervising attending physician, credentialed and granted privileges by the Medical Board, shall be physically present in the Emergency Department 24 hours per day, seven days per week.

2.9               All surgical procedures performed by a postgraduate trainee requiring general anesthesia or an operating room procedure must be personally supervised (direct visual supervision) by an attending physician privileged to perform the procedure.

2.10               Preoperative examination and assessment must be conducted by an attending physician.

2.11              Postoperative examination and assessment must be conducted no less frequently than daily by an attending physician.

2.12               There must be a sufficient number of supervising physicians present to meet reasonable and expected demand.

2.13               On-site supervision of routine hospital care and procedures performed by postgraduate trainees can be carried out by postgraduate trainees who are in their final year of training or who have completed at least three years of postgraduate training if and only if the patient’s attending physician or supervising physician is immediately available by telephone and readily available when needed.

2.14               The Department Chair and program director shall take disciplinary action and other corrective measures against trainees providing services that exceed the scope of their privileges.

Each program with postgraduate trainees shall have policies defining the supervision
of their postgraduate trainees in their discipline.

Physicians, dentists, and podiatrist credentialed by the Medical Board must be present to supervise postgraduate trainees in outpatient areas.

Supervision of postgraduate trainees in the outpatient setting must be documented in the medical record.

Each postgraduate training program shall monitor the supervision of postgraduate
trainees as part of their Quality Assurance activities.

Anthony Somogyi, M.D.             

Chairman, Graduate Medical Education Committee
Director, Graduate Medical Education