Supervision and Duty Hours

PEDIATRIC CRITICAL CARE MEDICINE FELLOWSHIP PROGRAM

Policy for Fellow

Supervision

Curriculum

  • This Program has established a curriculum that delineates the fellow’s responsibilities for patient care, provides progressive responsibility for patient management, and offers supervision of each fellow throughout the duration of the program
  • The written curriculum is provided to fellows during orientation and is also located within MedHub in electronic format.
  • This Supervision Policy satisfies the UIHC “GME Policy for Resident and Fellow Supervision” and all applicable specialty-specific standards required by accrediting and/or certifying bodies, including the ACGME and appropriate RRC.

Distribution of Program Policy

This policy is

  • given to each fellow by the Program at the outset of each training year
  • always available within MedHub (medhub.com)
  • provided to the GME Office before GME contracts are issued each academic year.
  • applicable at all sites where the fellows rotate, and each site must provide adequate supervision and engage fellows and fellows in standardized transitions of care consistent with the setting and type of patient care.

Supervisors:

  • Responsible practitioner - Each patient must have an identifiable, appropriately-credentialed and privileged physician (or licensed independent practitioner as approved by the RRC) who is ultimately responsible for each patient’s care; in every setting, the care of patients is supervised by faculty to the appropriate level of supervision and according to PGY level as specified in this policy.
  • Fellow’s access to identified supervisor: Fellows in the program will know which attending is on service by looking at the Faculty attending schedule posted at the desk within the PICU faculty office area.  The faculty attending is always available either in person, by telephone and/or by pager. 
  • Role clarification in patient care:  Each fellow and faculty member must inform every patient of their respective roles in each patient’s care.
  • Guidelines for fellows to communicate with supervisors:  At orientation, fellows receive the document titled, “Guidelines for Attending Involvement/ Notification for Procedures, Admissions, Consults” (see Attachment A) which details the expectations for each program year.  This document is also posted within MedHub for access at any time.
    • Inpatient:  Each patient admitted is assigned to the attending physician on duty.  The fellow must notify the attending physician of every admission and make the attending aware of the condition of all seriously ill patients.  Stable patients must be brought to the attention of the attending soon after the fellow develops a working diagnosis and treatment plan.  Daily attending rounds are made by the attending on service, who remains actively involved in directing patient care. 
  • Rotations:  Each rotation, on- or off-site, has direct supervision available, as required by PGY level in this policy.  For external rotations, an agreement with that site specifies the supervising physician. Our first year fellows have a one month Echo/Bronch rotation, supervised by Dr. Timothy Starner/ Dr. Benjamin Reinking, respectively.  Our second year fellows have a one month rotation through Cardiothoracic Surgery, supervised by Dr. Joe Turek.
  • Faculty and Fellow on-call schedules:  Our faculty call schedules and fellow call schedules are each provided to our fellows at the start of every 6 months (July to December and January to June).  These call schedules ensure that fellows know the appropriate supervisor to contact and that supervision is, therefore, readily available to those on duty.

Levels of Supervision

The program ensures that fellows assume progressively increasing responsibility according to each fellow’s level of education, ability and experience.  The appropriate level is determined by the teaching staff, as approved by the Program Director, and accorded to each fellow at the appropriate level of responsibility.  Faculty supervision assignments are of sufficient duration to assess the knowledge and skills of each fellow so that the supervising faculty can appropriately delegate to each fellow the authority and responsibility for portions of care based on the needs of the patient and the skills of the fellows.  Supervision does not equate merely to the presence of more senior physicians or dentists or with the absence of independent decision making on the part of fellows.  These supervision standards encompass the concepts of graded authority, responsibility and conditional independence that are the foundation of delegation of authority to more senior house staff members.
The program uses the following classifications of supervision to assign the privilege of progressive authority and responsibility, conditional independence and a supervisory role in patient care to each fellow, as appropriate:

  • Direct Supervision – The supervising physician or dentist is physically present with the fellow and patient.
  • Indirect Supervision

i)    with direct supervision immediately available – The supervising physician or dentist is physically present within the hospital or other site of patient care, and is immediately available to provide direct supervision.
ii)   with direct supervision available – The supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide direct supervision.

  • Oversight – The supervising physician or dentist is available to provide review of patient encounters with feedback provided after care is delivered.
  • Supervision by PGY Levels
    • PGY 1 fellows - are supervised either directly or indirectly with direct supervision immediately available while they acquire basic knowledge and skills specific to the specialty. 
    • PGY 2 and above - are supervised by any level of supervision, as appropriate to the patient situation and fellow capability. 

Supervision may be exercised through a variety of methods.  Some activities require the physical presence of the supervising faculty member.  For many aspects of patient care, the supervising physician may be a more advanced resident or fellow, based on the needs of the patient and the skills of the particular resident or fellow.  Other portions of care provided by the fellow can be adequately supervised by the immediate availability of the supervising faculty member or fellow physician, either in the institution, or by means of telephonic and/or electronic modalities.  In some circumstances, supervision may include post-hoc review of fellow-delivered care with feedback as to the appropriateness of that care.

Specific Activities/Procedures

See Attachment A for a list of specific activities/procedures and the related required level of supervision. 

Professionalism Expectations 

It is expected that each fellow must know the limits of his/her scope of authority and the circumstances under which he/she is permitted to act with conditional independence.  The Program Director clarifies these limits during orientation as well as within the “Guidelines for Attending Involvement/ Notification for Procedures, Admissions, Consults” (Attachment A)

Evaluations

Evaluations are performed by the Program Director (or faculty members, as appropriate) and assess each fellow’s abilities based on specific criteria.

  • These criteria are competency based and faculty attendings evaluate fellows based on these competencies following each rotation: patient care and safety, medical knowledge, professionalism, practice based learning and improvement, interpersonal and communication skills, quality improvement, and systems based practice.
  • Evaluations must include summative evaluations as follows:
    • Summative evaluations must assess whether the fellow has demonstrated sufficient competence to enter practice without direct supervision.  Based on the concepts of graded and progressive responsibility, supervision in the setting of graduate medical education must assure the provision of safe and effective care to the individual patient, assure each fellow’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine, and establish a foundation for continued professional growth.
    • Milestones – As applicable to ACGME-accredited programs, the specialty-specific milestones must be used as one of the tools to ensure that fellows are able to practice core professional activities without supervision upon completion of the program.

Protection from Retaliation

Concerns of inadequate supervision may be reported to the Program Director, Program Coordinator, any faculty member, the GMEC, the Associate Dean for GME, the GME Office, or the Compliance HELPLINE at 384-8190.  All calls are confidential and may be made anonymously, as chosen by the caller.  The UIHC protects all callers from retaliation.

Duty Hours

The Division of Pediatric Critical Care policy on fellow work hours follows the guidelines set by UIHC and by the Residency Review Committee of Pediatrics and Pediatric Critical Care.  This policy applies to all Pediatric Critical Care Fellows.  Specific mandated guidelines include: at least one day out of seven when averaged over four weeks without assigned duties; a maximum of 80 hours/week when averaged over four weeks; at least 10 hours off between shifts, and call no more frequently than every third night. Call free months are also built into the program. Fellows are instructed to log all hours worked into an electronic file which is monitored regularly by the program director.  The duty hour policies below are presented to and reviewed with the fellows at their original orientation to the program.  We have designed a schedule that complies with these rules on all rotations. The faculty is aware of the expected work hours for the fellows while rotating in the PICU and on other rotations. The program director meets semi-annually with each fellow and at this time the program director will directly solicit any concerns about meeting duty hour guidelines. The program director will discuss any apparent issues with meeting duty hour requirements with the fellow(s) when/if these conflicts occur. The program director will also independently spot check both hours worked by fellows and the recording of these hours.

Specific duty hour requirements are as follows:

Maximum Hours of Work per Week

The duty hours of any PICU fellow are limited to 80 hours per week when averaged over a 4-week period, inclusive of all in-house call activities and any moonlighting activities. Any time spent in the UIHC related to the fellowship program, both inpatient and research, shall count toward the weekly maximum.  Additionally, the weekly maximum shall include time spent for administrative duties related to patient care, the transfer of patient care, scheduled academic activities such as conferences, research related to the program, and any time the fellow spends on-site after being called in to the hospital.  Not included in the weekly maximum is time spent outside of UIHC (or outside another institution related to the program’s academic purposes) for academic preparation, reading, and studying.

Maximum Duty Period Length

  • In unusual circumstances, fellows, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring or humanistic attention to the needs of a patient or family. Fellows must appropriately hand over the care of all other patients to the team responsible for their continuing care.
  • PICU fellows have an established daily rounding/handoff sheet that they use for all patients in the unit.  A standardized Anesthesia/PICU handoff document is also used routinely when our fellows accept patients from the OR.
  • Any fellow exceeding maximum duty period lengths will document their justification in the institution’s fellow management system (i.e. MedHub). The program director will discuss any apparent issues with meeting duty hour requirements with the fellow(s) when/if these conflicts occur.

Maximum Frequency of Over-Night In-House On-Call Duties

In-house call must not be scheduled more frequently than every third night when averaged over a 4-week period. Currently fellows are assigned to take in-house call twice weekly during their rotations in the PICU. They leave the hospital on post call days by 11 am and do not return until the next morning at 7am. They also take call from home 1-2 weekends/month during their rotations in the PICU.  During the weekend of home call, if the fellow returns to the hospital after 9pm they are relieved of their duties the next day at 12 noon, and do not return until the following morning.  Fellows have access to on-call facilities when their call duties require in hospital overnight stay, and on any night that they are required to remain in the hospital for patient care, they must leave the hospital directly following rounds the next day (<28 hours continuously worked). During research months, anesthesia rotation, CV surgery, and other elective rotations fellows take in-house call one weeknight/week and are on call either from home 1 weekend/month or for scheduled 24 hour weekend shifts.  All of the above described guidelines for duty hours apply during these rotations as well.   

Mandatory Time Free of Duty

Fellows must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks).  This day off shall not include home call nor shall the fellow be required to carry a pager. A day is defined as 24 consecutive hours.

Minimum Time Off between Scheduled Duty Periods

  • PICU Fellows (as defined by the program’s RRC) – should have 10 hours, and must have 8 hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 continuous hours of in-house duty.
  • Final year PICU fellows (as defined by the program’s RRC) – can participate in transition to practice activities when they are preparing to care for patients over irregular or extended periods. It is still desirable that these fellows have 8 hours free of duty between scheduled duty periods, but there may be circumstances where residents must stay on duty to care for their patients or return to the hospital after shorter intervals.
  • The Program Director monitors time off between scheduled duty periods.

Home call

Fellows returning to the hospital from home call must count their time spent in the hospital towards the 80-hour maximum weekly hour limit. The frequency of home call is not subject to the every-third-night limitation but must satisfy the requirement for 1 day in 7 free of duty, when averaged over 4 weeks.

  • Home call activities must not be so frequent as to preclude rest and reasonable personal time for each fellow.
  • Fellows are permitted to return to the hospital while on home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period.”
  • PICU Fellows take call from home 1-2 weekends/month during their rotations in the PICU depending on their year of training.  During the weekend(s) of home call, if the fellow returns to the hospital after 9pm they are relieved of their duties the next day at 12 noon, and do not return until the following morning. 

Moonlighting

Moonlighting is governed by the Moonlighting Policy and Procedures for House Staff Physicians and Dentists. All requirements of that policy must also be followed, including visa and license requirements. In order to ensure against any adverse effects on the fellow's educational or clinical program, the following departmental policy has been established for fellows wishing to moonlight:

A.  Each fellow wishing to moonlight must submit a single request in writing to the Program Director (first) and the Department Head. The request will set forth the circumstances necessitating moonlighting. The form for making such a request may be obtained from the Program Director. The Program Director and Department Head will evaluate and respond to such requests on an individual basis. 

B.  Fellows must have a permanent physician's license to moonlight outside of the institution.

C.  Fellows must possess adequate professional liability insurance.  The professional insurance protection provided by the State Tort Claims Act does not protect the fellow when he or she is engaged in clinical practice outside of the scope of the training program.  The house staff member is responsible for obtaining appropriate medical malpractice/professional liability coverage for moonlighting activities.  Evidence of such insurance is required before approval is granted.

D.  Moonlighting is limited to times when fellows are not on the inpatient clinical rotation (allowed during research rotations)

E.  Moonlighting is allowed in a pediatric setting only.

F.  Total hours worked, including those hours worked as part of the training program and those hours devoted to moonlighting, must not exceed the standard set by the Pediatric Residency Review Committee/ACGME.  These standards state that each resident/fellow should have a monthly average of one day out of seven without clinical responsibilities and work no more than 80 hours per week on average, when averaged over four weeks. Moonlighting at UIHC counts toward the 80 hour work week.  Because of this requirement, moonlighting is allowed only during research rotations.

G.  Any fellow wishing to moonlight must have passed the American Board of Pediatrics Exam or obtained scores on the American Board of Pediatrics In-Training Examination which indicate the likelihood of passing the board exam after training is completed (currently:  PL2 exam score ≥ 300; PL3 exam score ≥ 360).

H. PGY 1 fellows are not permitted to moonlight.

The Pediatric Critical Care Medicine fellowship program meets the requirements of this policy as well as any applicable standard set by the ACGME, the appropriate RRC, or other accrediting or certifying body.  This policy is distributed by the GME Office to all GME contract holders as well as to all fellows at original orientation and all faculty members are at the start of their appointment, and to all PICU faculty and fellows as updates are made. The Pediatric Critical Care Medicine fellowship program monitors fellow duty hours with a frequency sufficient to ensure compliance with this policy and the ACGME/RRC/other accrediting or certifying body’s rules.