The ACGME and Joint Commission require that supervision expectations be readily available to trainees and faculty wherever training occurs. This page satisfies that requirement for the Rheumatology Fellowship program at the following sites:
University of Washington Medical Center, Harborview Medical Center, VA Puget Sound Health Care System.
Updated: May 6, 2026
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 responsible and accountable for the patient’s care. This information will be available through the electronic health record (EPIC, CPRS/Cerner), inpatient consult service assignment schedules on the UW Rheumatology Intranet.
The rheumatology 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:
1. Direct Supervision
- The supervising physician is physically present with the fellow and patient during the key portions of the patient interaction; or,
- 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.
2. Indirect Supervision
- The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.
3. 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 each fellow’s abilities based on specific criteria, guided by the Milestones.
Faculty members functioning as supervising physicians must delegate portions of care to fellows based on the needs of the patient and the skills 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. Senior residents or 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 Specialty Clinical Activities and Invasive Procedures
| Clinical Activity/Procedure | Fellow Level (time in program) | Location | Supervision Level | |||
|---|---|---|---|---|---|---|
| Outpatient clinic care | < 6 months of training | All | Direct | |||
| Outpatient clinic care | ≥ 6 months of training | All | Direct, indirect, or oversight (1) | |||
| Inpatient consult care | All
|
All | Direct, indirect, or oversight (1) | |||
| Prescription of chemotherapy | All | All | Direct | |||
| Arthrocentesis/joint injection; tendon sheath/nerve sheath injection; bursal injection/aspiration | All | All | Direct (2) | |||
|
1. Direct oversight is Program expectation for all services; however, if supervising physician is temporarily unavailable, indirect or oversight supervision is allowed. 2. The clinical competency committee may determine that for specific procedures or classes of procedures, a fellow only needs indirect or oversight supervision. |
Note: For all activities listed above, level of supervision for residents/medical students is direct. When a fellow directly supervises a resident/medical student, the resident’s/medical student’s supervision level is that of the fellow.
Circumstances and Events in which Supervising Faculty Member(s) MUST be Contacted
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All activities requiring direct or indirect supervision (above).
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Severe adverse reaction to any therapy prescribed by/recommended by fellow or trainee’s supervising faculty member.
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Prescription/recommendation of medical therapy in children (age < 18) and pregnant patients.
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Request by legal counsel for information regarding patient care, research, or training.
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Request by journalists for information regarding patient care, research, or training.
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Fellow requesting unexpected leave (sick leave, emergency, etc.)
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Adverse patient events
Supervision of Consults
Fellows performing consultations on patients are expected to communicate verbally with their supervising attending at the following time intervals: daily.
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 are of 1-week (inpatient consult service) and 12 months (continuity clinics) duration and therefore are of sufficient length to assess the knowledge and skills of each resident/fellow and to delegate to the resident/fellow the appropriate level of patient care authority and responsibility.
Supervision of Handoffs
Fellows conducting hand-offs are expected to use structured verbal and electronic processes for patient transfers between services and locations, such as EPIC and CPRS/Cerner patients lists, and de-identified emails (see separate Handoff Policy).
Fellows may be supervised directly or indirectly when conducting hand-offs. PGY-1 residents should initially be directly supervised when conducting hand-offs.
Faculty must assess fellow readiness to move from direct to indirect supervision when conducting hand-offs and patient transfers using the following direct observation during the first 3 months of training and adequate progress toward Milestones in subcompetencies SBP2, SBP3, PROF3, and ICS2, as determined by the Program director or the clinical competency committee (CCC).
The Program’s Handoff Policy can be found on the Fellowship Resources SharePoint site.