Palliative Medicine Fellowship Program Supervision and Accountability Policy

Last Reviewed: March 25, 2026
Last Updated: March 25, 2026

This policy applies to fellows appointed under the ACGME-accredited Geriatric Medicine Fellowship Program in the UW School of Medicine Graduate Medical Education programs and is governed by the Institutional Supervision and Accountability Policy the Residency and Fellowship Position Appointment (RFPA) Agreement. In the event of any conflict, the institutional GME Policy and the RFPA supersede this program-specific policy.

Please reference complete UW GME Institutional Supervision and Accountability Policy for additional definitions and background.

Responsibilities and Accountability

Each patient must have an identifiable and appropriately-credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable Review Committee) who is ultimately responsible and accountable for the patient’s care. This information will be available at each individual site to fellows, faculty member, other members of the health care team through site-specific electronic records including MedHub, Epic, WebOncall, and/or Outlook.

The Palliative Medicine fellows and faculty members must inform each patient of their respective roles in that patient’s care when providing direct patient care.

The program will provide the appropriate level of supervision for each fellow based on each fellow’s level of training and ability, as well as patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation.

As part of their education program, fellows are given graded progressive responsibility according to the individual’s clinical experience, judgment, knowledge, and technical skill. Each fellow must know the limits of their scope of authority, and the circumstances under which the fellow is permitted to act with conditional independence.

Supervision Definitions

To promote oversight of fellow supervision while providing for graded authority and responsibility, the following levels of supervision are recognized. Note: we are using language of supervising physician but please note that this means attending physician or licensed independent practitioner.

Direct Supervision

1. The supervising physician is physically present with the fellow and patient during the key portions of the patient interaction; or,
2. The supervising physician and/or patient is not physically present with the resident and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.

Indirect Supervision

The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately reachable by the fellow via phone or other secure telecommunication methods for guidance and is available to provide appropriate direct supervision within 30 minutes. This applies across all participating training sites.

Oversight

The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

Resident Competence & DelEGATED AUTHORITY

The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each fellow must be assigned by the program director and faculty members.

The program director must evaluate and document each fellow’s competence based on specific criteria, guided by the Milestones.

Faculty members functioning as supervising physicians must delegate portions of care to fellows based on both the needs of the patient and the competence of each fellow.

CLINICAL RESPONSIBILITIES BY PGY-LEVEL

Fellows

Fellows may be directly or indirectly supervised. They may provide direct patient care, supervisory care or consultative services, with progressive graded responsibilities as merited. Fellows should serve in a supervisory role to medical students, junior and intermediate residents in recognition of their progress towards independence, as appropriate to the needs of each patient and the skills of the fellow; however, the attending physician is responsible for the care of the patient.

Levels of Supervision for Common Clinical Activities and Invasive Procedures

Any clinical activity or procedure not explicitly listed in this table requires prior discussion with the supervising attending to determine the appropriate level of supervision before the activity is performed.

Clinical Activity/Procedure	Resident level (PGY) (fellows are PGY4 or greater)	Location	Supervision Level
Inpatient Consultation	4	Inpatient	Direct supervision at the initiation of fellowship progressing to indirect supervision with direct supervision available
Clinic Visits	4	Ambulatory	Indirect supervision with direct supervision available
Home Visits	4	Ambulatory	Oversight

In a training program, as in any clinical practice, it is incumbent upon the physician to be aware of their own limitations in managing a given patient and to consult a physician with more expertise when  necessary. In all cases, the attending physician (or licensed independent practitioner) is ultimately responsible for the provision of care by fellows. When there is any doubt about the need for supervision, the attending should be contacted.

Circumstances and Events in which Supervising Faculty Member(s) MUST be Contacted

There are specific circumstances and events in which fellows must communicate with appropriate supervising faculty members to report adverse events, near misses, unsafe conditions, or other patient safety concerns. These circumstances include death of a patient, need for a patient to transfer to an ICU setting, medical errors involving a patient (including those that do not cause direct patient harm), or events that might lead to legal action. In these circumstances, the attending should be notified as soon as possible after the event. If the attending physician does not respond in a timely fashion, the fellow is encouraged to contact the (1) the program director or (2) any other available faculty member within the palliative medicine program. Fellows must also follow institutional patient safety reporting processes.

Supervision of Consults

Fellows performing consultations on patients are expected to communicate verbally with their supervising attending at the following time intervals: within 24 hours or sooner based on the urgency of the consultation.

Emergency Procedures

It is recognized that in the provision of medical care, unanticipated and life-threatening events may occur. The fellow may attempt any of the procedures normally requiring supervision in a case where death or irreversible loss of function in a patient is imminent, and an appropriate supervisory physician is not immediately available, and to wait for the availability of an appropriate supervisory physician would likely result in death or significant harm. The assistance of more qualified individuals should be requested as soon as practically possible. The appropriate supervising practitioner must be contacted and apprised of the situation as soon as possible.

Faculty Supervision Assignment

Faculty supervision assignments must ensure continuity of oversight of sufficient length to assess fellow competence and adjust levels of supervision as appropriate.

Supervision of Handoffs

Fellows conducting hand-offs are expected to use structured verbal and electronic processes for patient transfers between services and locations using secured shared handoff forms and/or handoff tools in the electronic medical records.

Fellows may be supervised directly or indirectly when conducting hand-offs.

Faculty must assess fellow readiness to move from direct to indirect supervision when conducting hand- offs and patient transfers using direct observation.

Faculty must assess fellow readiness to move to indirect supervision when conducting hand-offs and patient transfers using the following: direct observation or guided discussion prior to transitions to assess readiness for handoffs in addition to post-handoff debriefs to further optimize care transitions.

Program Handoffs Guidelines

Hand-offs are a time of utmost importance for continuity of care and patient safety. Patient hand-offs occur under indirect attending supervision based on the experience and skill of the individual fellow.

Inpatient Setting

When the fellow leaves at the end of the work day, leaves to go to another clinical or didactic experiences, or is leaving prior to a day off or vacation, the fellow must ensure that all relevant patient information including the need for follow up of tests, procedures, and consults is communicated to the attending physician or resident/fellow to whom this responsibility has been delegated in person, by telephone, and/or in writing. In the inpatient setting, fellows may delegate the hand-off of patient information to resident physicians, as long as they ensure that the hand-off is being clearly communicated to the receiving resident or fellow, and the attending physician and fellow agree that the resident is competent to perform the handoff without direct supervision. The attending is ultimately responsible for patient care, so should be notified of any unstable patients, critical tests, or any pending invasive procedures even if the fellow and attending have delegated this responsibility to a resident.

Outpatient, long term care, and home care settings

Fellows, under the indirect supervision of attendings, are responsible for ensuring that patient information is communicated in writing or via phone with the attending, licensed independent practitioner and/or fellow taking over responsibility of the patients. This includes ensuring that any test, consult, or procedure ordered by the fellow has appropriate follow up. The attending physician (or licensed independent practitioner) is ultimately responsible for the safety of handoffs, so any pending tests, procedures, or consults should be communicated to the attending of record (or licensed independent practitioner) prior to a fellow going on vacation, transitioning to another clinical rotation, and at the completion of fellowship. If the fellow is unsure to whom the patient should be handed-off, a supervising attending or program director should be notified to assist with determining the appropriate person to whom a clinic, long term care, or home care patient should be handed off.

Faculty Development and Fellow Education around Supervision and Progressive Responsibility

Attendings should adhere to the SUPERB model when providing supervision. They should:

1. Set Expectations: set expectations on when they should be notified about changes in patient’s status.
2. Uncertainty is a time to contact: tell resident to call when they are uncertain of a diagnosis, procedure or plan of care.
3. Planned Communication: set a planned time for communication (i.e. each evening, on call nights)
4. Easily available: Make explicit your contact information and availability for any questions or concerns.
5. Reassure fellow not to be afraid to call: Tell the fellow to call with questions or uncertainty.
6. Balance supervision and autonomy.

Fellows should seek supervisor (attending or senior resident) input using the SAFETY acronym.

1. Seek attending input early.
2. Active clinical decisions: Call the supervising resident or attending when you have a patient whose clinical status is changing and a new plan of care should be discussed. Be prepared to present the situation, the background, your assessment and your recommendation.
3. Feel uncertain about clinical decisions: Seek input from the supervising physician when you are uncertain about your clinical decisions. Be prepared to present the situation, the background, your assessment and your recommendation.
4. End-of-life care or family/legal discussions: Always call your attending when a patient may die or there is concern for a medical error or legal issue.
5. Transitions of care: Always call the attending when the patient becomes acutely ill and you are considering transfer to the intensive care unit (or have transferred the patient to the ICU if patient safety does not allow the call to happen prior to the ICU becoming involved).
6. Help with system/hierarchY: Call your supervisor if you are not able to advance the care of a patient because of system problems or unresponsiveness of consultants or other providers.

This policy has been reviewed for consistency with the current UW GME Institutional Supervision and Accountability Policy and the applicable academic year RFPA.