Section 5: Progressive Responsibility and Supervision

Progressive Responsibility Policy in the ICU

This policy guides the incremental assumption of patient care responsibilities by pulmonary critical care fellows during ICU rotations, in accordance with the “NMCSD GRADUATE MEDICAL EDUCATION POLICY: Resident Supervision and Accountability”. The goal is to cultivate independent decision-making, high standards of patient care, and professional growth, ensuring that fellows progress through appropriate levels of supervision (Direct Supervision, Indirect Supervision, Oversight) as they demonstrate competence. Fellows’ clinical judgment, procedural skills, knowledge base, communication, teamwork, and commitment to continuous learning are regularly evaluated.

First-Year Fellow Policy for ICU Rotations

Focus: Learning ICU procedures, patient safety, decision-making, and critical patient-care fundamentals.
Supervision: Initially, fellows operate under Direct Supervision, similar to a senior resident transitioning to a new role. All significant treatment decisions must be reviewed with the attending physician before implementation.
Independence: Fellows gain progressive responsibility based on demonstrated competence, moving towards Indirect Supervision for certain tasks as deemed appropriate by the attending.
Leadership: Fellows lead patient care teams with close attending oversight (Direct or Indirect Supervision as appropriate), including bedside teaching and running ICU rounds.

Second-Year Fellow Policy for ICU Rotations

Scope: Expected to manage most admissions with an increased level of autonomy, typically under Indirect Supervision for routine matters, but with Direct Supervision readily available and utilized for complex or unstable patients.
Consultation: Required for severe/newly intubated patients or when refusing admissions, involving the attending physician (Direct Supervision for critical decisions).
Independence: Higher autonomy based on prior performance, but attendings remain available for complex cases and critical decision-making.

Third-Year Fellow Policy for ICU Rotations

Expertise: Should function at a high level of proficiency, managing routine scenarios under Oversight or Indirect Supervision, while appropriately seeking Direct Supervision for complex procedures or high-risk situations.
Leadership: Guides junior fellows and residents, preparing them for independent practice, and may assume certain supervisory roles as delegated and appropriate for their level of training and the patient’s needs.
Supervision Levels: Primarily Indirect Supervision or Oversight for standard tasks; Direct Supervision for high-risk or intricate procedures and critical patient events.

Exceptions to Progressive Responsibility

Regardless of training year, fellows must:

Notify the attending before accepting inter-facility transfers (requiring Direct Supervision for the decision-making process).
Inform the attending immediately about unexpected complications, rapid deterioration, death, or changes in resuscitation status, ensuring Direct Supervision or immediate availability of the attending for these critical events.

Progressive Responsibility on the Consult Service

These principles also govern fellows’ responsibilities on pulmonary consults, ensuring appropriate levels of supervision are applied:

First-Year Fellows

Must discuss each new patient with the attending on the day of consultation, operating under Direct Supervision for initial assessment and plan development. Typically, daily bedside rounds occur with the first-year fellow and attending.

Second-Year Fellows

Present new inpatient consultations to the attending within 24 hours. Initial plans may be formulated with more autonomy (Indirect Supervision) but must be confirmed with the attending. Bedside rounds occur at least twice weekly, or more frequently based on patient acuity, with Direct or Indirect Supervision as appropriate.

Third-Year Fellows

Function with greater independence, similar to junior faculty, often under Oversight for routine consults. They supervise junior fellows and must inform the attending of all new patients the same day. Formal presentations for straightforward cases may not be necessary, but critical findings or complex plans require discussion with the attending (Direct or Indirect Supervision as needed).

Progressive Responsibility in Continuity Clinic

Fellows’ responsibilities in continuity clinic also follow a graduated model of supervision, as outlined in Section 7 of this handbook.

Progressive Responsibility in Procedures

Detailed procedural supervision guidelines appear in Section 6 of this handbook. All fellows receive training under Direct Supervision until deemed competent for progression to Indirect Supervision or Oversight for specific procedures, in accordance with the “NMCSD GRADUATE MEDICAL EDUCATION POLICY: Resident Supervision and Accountability”. Competency requirements include:

Thorough knowledge of the procedure, including risks, benefits, indications, and contraindications.
Compliance with hospital policies.
Preparedness for potential complications.
Maintenance of documentation and adherence to adverse-event protocols.
Safe, effective procedural practice.

Once a fellow demonstrates competence for a given Category A procedure, the Program Director will issue a written certificate authorizing the fellow to perform that procedure under the appropriate ACGME-defined level of supervision (Indirect Supervision or Oversight), as determined by the responsible faculty and institutional policy. However, certain complex procedures (“Category B” and “Category C,” such as EBUS bronchoscopy, rigid bronchoscopy, percutaneous tracheostomy, navigational bronchoscopy, and medical thoracoscopy) always require Direct Supervision. Intubations in critically ill inpatients also mandate Direct Supervision, even if considered “Category A,” due to higher risk.

Note: Competency certification and the assigned level of supervision can be modified at any time by the Program Director or department chair if concerns arise regarding a fellow’s clinical judgment or patient safety practices.

References and Appendices

Section 5 Appendix 1: NMCSD GRADUATE MEDICAL EDUCATION POLICY: Resident Supervision and Accountability (22 January 2024)