I. Purpose: To delineate policy and procedures concerning oral and maxillofacial surgery resident supervision.
II. Policy: Community Medical Centers’ Ambulatory Care Center Oral and Maxillofacial Surgery Service provides appropriate clinical supervision for Community’s Oral and Maxillofacial Surgery (OMFS) residents. Robert S. Julian, D.D.S., M.D., is director of the OMFS Residency. Dr. Julian is responsible for the quality of the dental/medical education provided to OMFS residents and for ensuring that the program is in compliance with ADA post-graduate education standards. Community’s OMFS Service provides faculty supervision and residents the opportunity to assume increased responsibility for patient care according to their level of education, ability and experience, as determined by their faculty supervisors.
- This increase in clinical responsibilities shall be determined by the following criteria:There will be increasing levels of a resident’s clinical responsibilities as he/she moves through four years of post-graduate training. The appropriate level of supervision for such residents by the OMFS attending is based on the nature of patient medical/dental problems and the experience, judgment and skill of the resident being supervised. Third- and fourth-year OMFS residents can serve in a direct supervisory role of first- and second-year residents with the attending OMFS taking ultimate responsibility for all such patient care via indirect supervision.
- There will be resident evaluation/promotion criteria to assist attending OMFS staff in determining advancement between levels of responsibility. Competency-Proficiency Statements are used by the OMFS Education Program to evaluate residents every four months.
- This OMFS residency program will provide attending supervisors with a mechanism for assessing a resident’s clinical judgment and skills to identify one who is not achieving the progression in necessary skills. This mechanism is found in the Documentation Protocol for Goals, Objectives and Competency-Proficiency Statements of Graduates of the UCSF Fresno Oral & Maxillofacial Surgery Residency Program. The evaluation document and its essential elements are provided to each resident upon entry into the four-year OMFS residency.
- There will be decreasing levels of attending supervision for a resident who logically progresses in skill base with increasing independence. This will be accomplished by faculty certification that a competency or proficiency statement has been met. Progressive levels of competency would allow for decreasing levels of supervision for a particular skill or procedure.
III. The Oral and Maxillofacial Surgery Residency will provide quality patient care services through its residents, in conjunction with attending supervision that is at or above the community standard of care.
The mechanisms for achieving this are as follows:
- The levels of clinical responsibilities awarded to each resident are defined by resident year (PGY 1, 2, 3, and 4) in terms of specific procedural resident competencies that may be performed without supervision. For the OMFS program procedures and skills, please refer to sections 2 and 3. These resident competencies are available to inpatient/outpatient clinical staff electronically or in hard copy so the community standard of care can be assured in either setting.
- A supervising attending OMFS surgeon must be available to oversee the resident staff for the entire duration of patient care within the hospital, ambulatory care or emergency service site.
- Supervising attending OMFS surgeons may only supervise residents in areas/procedures which they themselves hold clinical privileges within the Community Medical Centers health care system.
IV. The Oral and Maxillofacial Surgery Residency ensures there will be sufficient and appropriate attending-resident communication to provide the very highest quality of patient care and enough supervision for an excellent educational experience.
This will be done in the following manner:
- There will be a mutual responsibility to recognize the need for increased communication and supervision under the following circumstances:
- A significant deterioration in clinical status
- Any patient with a high risk condition (critically ill, airway or bleeding concerns)
- Uncertainty regarding the diagnosis
- Uncertainty regarding the proposed clinical management of the patient
- Patients requiring procedures or interventions, which entail significant risk
- The nature of this communication between the attending OMFS surgeon and the resident would by as outlined under levels of supervision in section II, 1. Essentially, increased levels of communication would translate to increase levels of supervision required to assure the highest standards of patient care.
V. The Oral and Maxillofacial Surgery Residency will actively monitor and document the resident-attending communication and supervision in a way that demonstrates the high quality of patient care given and also satisfies the needs of all relevant accrediting bodies.
This will be accomplished in the following manner:
- There will be an OMFS residency specific policy-procedure for an active monitoring-feedback process to the Program Director or designee, at each appropriate affiliated site, in conjunction with the performance improvement staff at that facility. This would include, but not be limited to the following elements:
- Admitting orders must specify the attending OMFS surgeon of record.
- Evidence of daily communication between resident and attending staff should be documented in the patient’s medical record by the attending or, at his or her request, by the resident referencing the communication.
- The attending faculty on the requesting service should approve consultation requests.
- Completed consultations should include evidence of faculty participation and supervision within 24 hours of completion by the resident staff.
- The Program-Specific monitoring-feedback process with the Performance Improvement (PI) Staff to the OMFS Program Director or designee at the facility will be as follows:
The PI staff will review records for proper documentation as well as progress in developing the documentation for the required competency-proficiency statements under each OMFS Residency goal.
RESIDENT COMPETENCIES AND LEVEL OF SUPERVISION
|Extraction, erupted teeth||X||X||X||X|
|Extraction, impacted teeth||X||X||X||X|
|Biopsy, soft tissue||X||X||X||X|
|Repair laceration, simple||X||X||X||X|
|Repair laceration, complex||X||X||X||X|
|Steroid Injection, TMJ||X||X|
|Arch bar, application||X||X||X||X|
|Arch bar, removal||X||X||X||X|
|History and Physical||X||X||X||X|
|Airway management, intubation||X||X||X|
|Application of local anesthesia||X||X||X||X|
|Arterial Blood Gases||X||X||X|
|Arterial Line, application/removal (A/R)||X||X||X||X|
|Closed Reduction, Facial Fracture(maxilla, mandible, nasal)||X||X||X|
|Cast/splint (A/R)(for fracture, protection, immobilization||X||X||X||X|
|Central Line (femoral, jugular, subclavian), Insert||X|
|Central Line (femoral, jugular, subclavian), Remove||X||X||X||X|
|Chest Tube, insert||X|
|Chest Tube, remove||X||X||X|
|Cultures (wound, urine, sputum, blood)||X||X||X||X|
|Defibrillation, emergency (ACLS protocol)||X||X||X||X|
|Drainage tube (not chest or mediastinal), insert||X||X||X||X|
|Removal of drainage tube (all)||X||X||X||X|
|Drug administration, IM||X||X||X||X|
|Drug administration, IV||X||X||X||X|
|Foley Catheter (I/R)||X||X||X||X|
|Incision and Drainage, abscess, cyst, seroma, hematoma||X||X||X||X|
|Fiber optic Nasopharyngoscopy||X||X|
|Nasal Packing, anterior and posterior (I/R)||X||X||X||X|
|Other wound care, change/replace dressing, clean||X||X||X||X|
|Percutatneous needle aspiration (biopsy or drainage)||X||X||X||X|
|Perform/interpret lab tests (hct, ua, EKG, gram stain)||X||X||X||X|
|Remove foreign body||X||X||X||X|
|Swan Ganz Catheter, insert||X|
|Swan Ganz Catheter, remove||X||X||X||X|
|Venous line (I/R)||X||X||X|
|Excision of Cyst, Tumors of the maxillofacial area||X||X||X|
|Dental Implant (I/R)||X||X||X|
|Repair of Dentalveolar injuries||X||X||X||X|
|Endodontic surgery (apicoectomy)||X||X||X|
|Maxillary Sinus Aspiration and Lavage with cultures||X||X||X||X|
|Office Visit, simple||X||X||X||X|
|Office Visit, intermediate||X||X||X||X|
|Office Visit, Complex||X||X||X||X|
|Post-operative office visit||X||X||X||X|
|RFTA palate (radio frequency tissue ablation)||X|
|Excision of Mandibular/Maxillary tori (exostosis)||X||X||X||X|
|Caldwell-Luc with nasal antrostomy||X||X|
|Surgical Drain (I/R)||X||X||X||X|