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General Guidelines for College-Directed Clinical Supervision

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The CPSNS acknowledges the CPSO from whose source documents, with permission, this guideline was adopted. 

Introduction

The College, through its committees, policies and regulations, may require that a physician’s practice be supervised.

Examples of College-directed Clinical Supervision include:

  1. The Registrar or Registration Committee will require supervision for a physician holding a Defined licence;
  2. An Investigations Committee may require supervision when the investigation of a physician’s practice identifies the need for practice improvements and/or identifies patient safety concerns;
  3. An Investigations Committee may require supervision as an interim measure pending a formal Investigation or Hearing;
  4. An Investigations Committee, the Registrar or the Registration Committee may require supervision where a physician has a health-related issue that may interfere with their ability to provide safe patient care;
  5. The Registrar or Registration Committee may require supervision for a physician who is changing their scope of practice or re-entering practice after an absence of more than three years (See Medical Practitioners Regulations, Section 16 (1) and (2)).
  6. The Practice Review Committee may require supervision for a physician who, in the course of Peer Review, is identified as requiring practice improvement that cannot be otherwise achieved;
  7. The Physician Performance Department may recommend supervision for a physician who requires practice improvement that cannot otherwise be achieved.

Purpose of these Guidelines

These guidelines set out the College’s general expectations and processes for physicians engaged in College-directed supervision with regard to:

  • terminology;
  • principles of supervision;
  • qualifications and characteristics of an acceptable Supervisor;
  • terms of supervision;
  • approaches to supervision
  • basis for immediate reports to the College;
  • roles of Supervisors and Supervised Physicians, including the general responsibilities of these parties to each other and the College; and
  • compensation of Supervisors.

This document does not pertain to supervision in accredited educational settings, such as undergraduate medical education or postgraduate specialty and sub-specialty training. Physicians licensed for the purpose of a formal clinical fellowship are also excluded from these guidelines.

Terminology

Clinical Supervision is the process under which a physician (or group of physicians) are engaged as agents of the College to formally oversee and assess another physician’s practice for the purpose of ensuring that the care provided meets the expected standard. Clinical Supervision commonly includes an education component for the Supervised Physician.

A Clinical Supervisor is a physician who enters into a formal arrangement, as an agent of the College, under which they agree to oversee and assess another physician’s practice for the purpose of ensuring that the care provided meets the expected standard. The Clinical Supervisor is commonly expected to provide education and guidance to the supervised physician.

Exclusions

The following roles are addressed elsewhere:

The term Practice Monitor is used to describe an individual (not necessarily a physician) who is engaged as an agent of the College to ensure that the monitored physician practices according to conditions or restrictions placed upon their licence (e.g. posting a sign, using a chaperone or limiting the scope of practice).

The term Health Monitor is used to describe an individual (typically a physician or other professional) who is engaged as an agent of the College to ensure that the monitored physician maintains a level of personal health necessary to provide safe and effective care to patients (e.g. for issues of physical health, mental health or substance misuse).

The term Mentor is used to describe a trusted individual who established a relationship with the mentored physician for the purpose of modeling behaviour, offering advice, education or support. This is considered an informal arrangement in that it does not have specific goals and objectives, or a reporting requirement to the College.

Principles of Supervision

When the principles of Clinical Supervision are applied in a consistent and responsible manner, supervision will promote quality physicians, patient safety and public trust. The principles of supervision are:

  1. Safe, quality patient care must take priority in all Supervisory situations.
  2. The Supervisor’s ultimate responsibility is to the College, and both the Supervisor and Supervised Physician must adhere to the Terms of Supervision agreement with the College.

Qualifications and characteristics of an acceptable Clinical Supervisor

The College holds the authority to approve or decline a Clinical Supervisor. Depending on the circumstances, the College may encourage or require the Supervised Physician’s Sponsor and/or the relevant Health Authority to nominate potential Clinical Supervisors.

Approaches to Supervision

A team-based approach to Clinical Supervision is sometimes acceptable and desirable, but must be formally approved by the College. In this case, one physician will be identified as the ‘Lead Clinical Supervisor’ and will be the primary contact for the College.

Remote Clinical Supervision, including case discussions and record reviews using secure technologies, may in certain circumstances, be acceptable to the College.

The College’s Criteria for Approval of Clinical Supervisors

A newly nominated Clinical Supervisor must not be the subject of an open College complaint.

Any College complaint received on a physician already acting in the capacity of Clinical Supervisor will be reviewed to ensure that the matter does not undermine the College’s confidence in the quality of supervision.

In addition, the College considers the following criteria in determining whether to approve a Clinical Supervisor (the College may exercise discretion on any individual criterion):

  • registration with the CPSNS and one of: a Full Licence, an Academic Licence*;
  • practises in Nova Scotia;
  • unless otherwise approved by the Registrar, engaged in a scope of practice similar to that of the Supervised Physician;
  • a minimum of three years consecutive practice in the scope of practice to be supervised;
  • member’s complaints and investigations history acceptable to the College;
  • member’s assessment history (except as privileged under the Medical Act for the purpose of Peer Assessment) acceptable to the College;
  • member’s past performance as a supervisor (if any) acceptable to the College;
  • able to maintain collegial and constructive relationship with the College;
  • proximity and availability to the Supervised Physician appropriate to fulfill the responsibilities of supervision;
  • has sufficient time and resources necessary to take on the responsibility of supervising the physician and fulfill all requirements of the Terms of Supervision;
  • ability to provide constructive and objective feedback;
  • experience in, or willingness to learn about, the education and evaluation of practicing physicians;
  • a strong sense of professional responsibility and commitment to peer support;
  • not involved in activities that would compromise their ability to be a Clinical Supervisor;

*Note that the Medical Practitioners Regulations allows a supervisor who holds a “defined licence, and no longer requires supervision“. This is an internal inconsistency, in that Defined licence holders require supervision for the duration of that licence type. Therefore, no holder of a Defined licence will be appointed as a Clinical Supervisor.

In addition to the above, the College also considers relationships that could exist between the Clinical Supervisor and the Supervised Physician.

Disclosure of a pre-existing relationship between Clinical Supervisor and Supervised Physician 

The Supervisor and Supervised Physician must disclose to the College any pre-existing relationship. The College will determine whether the nature of the relationship disqualifies the proposed Supervisor, i.e. whether the relationship might interfere with the Supervisor’s ability to objectively evaluate the Supervised Physician.

Examples of relationships that may disqualify a proposed Supervisor include (but are not limited to): employment, family, social/personal, and business. As noted, the College will determine whether alternative supervision arrangements are warranted.

Financial Relationship between Supervisor and Supervised Physician 

The College will set the conditions of an administer all financial matters related to supervision, including costs to the Supervised Physician and remuneration (if any) to the Clinical Supervisor. In all circumstances, the responsibility of the Clinical Supervisor is to the College. Direct financial arrangements between Supervised Physician and Clinical Supervisor will not be considered.

 

The Terms of Clinical Supervision

The terms of Clinical Supervision will be determined by the relevant College Department or Committee, and informed by regulations and policy.

The terms of supervision may only be changed by or with the approval of the College.

The Clinical Supervisor and Supervised Physician must discuss the terms of supervision (i.e. nature, duration, level and frequency of reports) through an initial face-to-face meeting. Discussion via telephone or a secure web-based technology acceptable to the College may be permitted in certain circumstances.

The College determines when the Clinical Supervision phase is complete. This may involve a re-assessment or re-inspection of the Supervised Physician’s practice; a determination of whether the goals of the supervisory relationship have been met; or in some circumstances a determination of whether a licence may be issued that enables unsupervised practice.

The Supervisor may not withdraw from Clinical Supervision without giving adequate notice, as determined by the College and agreed to in the Terms of Supervision document.

Basis for Immediate Reports to the College

The general obligations for reporting by Nova Scotia Physicians are laid out in College policies and guidelines, including Reporting Requirements for Nova Scotia Physicians – Guidelines, and Sexual Misconduct in the Physician Patient Relationship – Policy.

The Supervisor’s additional and specific obligations will be set out in the Terms of Supervision with the College, but generally include the requirement for Supervisor to report immediately to the College in the following situations:

  • there are concerns about the Supervised Physician’s practice (i.e. practice below a reasonable standard, or which exposes patients to risk of harm or injury);
  • the Supervised Physician is practicing outside the scope or setting approved by the College;
  • the Supervised Physician’s conduct presents concern;
  • the Supervised Physician is acting in such a manner that suggests that he/she may be impaired or incapacitated;
  • the Supervised Physician fails to comply with the terms of supervision, including missing an appointment or meeting with the Clinical Supervisor without good reason, or being uncooperative;
  • the Clinical Supervisor is unable to continue in the role, or is unable to fulfill the obligations agreed to in the Terms of Supervision on a permanent or temporary basis (e.g. due to illness, personal emergency, etc.);
  • the Clinical Supervisor becomes the subject of a complaint to the regulator, either in Nova Scotia or another jurisdiction, or;
  • the Supervised Physician ceases to practice within the Health Authority.

Report immediately by phone to:

 

Clinical Supervision Reports

The Clinical Supervisor’s Terms of Supervision will lay out the schedule for providing reports to the College. It is essential that the Clinical Supervisor meets this schedule to enable the College to monitor the supervisory arrangement.

The Clinical Supervisor will be provided with a template upon which his/her report will be based. All reports will be signed and dated by the Clinical Supervisor.

Unless otherwise stated, the expected standards of practice will be those laid out in CPSNS policies and guidelines, and those established for the Supervised Physician’s specialty by the Royal College of Physicians and Surgeons of Canada (RCPSC) or the Canadian College of Family Physician (CFPC).

Reports must be objective, fair and impartial.

Reports must provide sufficient information to allow the College to make a determination as to whether the expected practice standards are being met and patient safety thereby assured.