Guidelines for College-Directed Supervision

Introduction

The College, through the Medical Act (2011) and Regulations, or its Committees and Policies, may

require that a physician’s practice be supervised.

Examples of College-directed Supervision include:

1. The Medical Act requires supervision for a physician who holds a Defined licence;
2. The Registrar or Registration Committee requires supervision for a physician who has been referred for concerns related to competency / performance in practice;
3. 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;
4. The Registrar or Registration Committee may require supervision for a physician who is changing their scope of practice or re-entering practice after a period of absence and deemed out of currency;
5. 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;
6. An Investigations Committee may require supervision as an interim measure pending a formal Investigation or Hearing;
7. The Practice Enhancement  Committee may require supervision for a physician who, during the course of an assessment is identified as requiring practice improvement that has not been achieved through the Practice Enhancement  process.

Purpose of these Guidelines

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

• terminology;
• principles of supervision;
• qualifications and characteristics of an acceptable Supervisor;
• terms of supervision;
• approaches to supervision;
• basis for immediate reports to the College; and
• compensation of the Supervisor.

This document does not pertain to supervision in accredited educational settings, such as undergraduate medical education or postgraduate specialty and subspecialty training.

In addition, this document does not pertain to physicians who are licensed by the College, requiring supervision under these circumstances:

• Formal Clinical Fellowship training program;
• Academic licence;
• Internal or External moonlighting;
• Physician Associates on a Clinical Assistant Licence; or
• Clinical Assessment under the Nova Scotia Practice Ready Assessment Program in Family Medicine.

Terminology

College-directed Supervision is the process under which a Supervisor is engaged as an Agent of the College to formally assess another physician’s practice for the purpose of ensuring that the care provided meets the expected standard. College-directed Supervision commonly includes an educational component for the physician under supervision

A Supervisor is a physician who enters into a formal arrangement, as an Agent of the College, under which they agree to assess another physician’s practice for the purpose of ensuring that the care provided meets the expected standard. The Supervisor is commonly expected to provide professional development educational resources 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 establishes a relationship with the mentored physician for the purpose of modeling behavior, 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 College-directed 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 Physician under Supervision must adhere to the Terms of Supervision¹ agreement with the College.

Terms of College-directed Supervision

The terms of College-directed Supervision1 will be determined by the Registrar or relevant College Committee and informed by Regulations and Policy. These terms may only be changed by the Registrar or the relevant College Committee.

The supervisor and physician under supervision must meet with the College’s Physician Performance Department to discuss the terms of supervision (i.e. nature, duration, level and frequency of reports) through an initial meeting (in person, video or teleconference).

The Registrar or relevant College Committee determines when the Supervision phase is complete. This may involve a re-assessment or re-inspection of the physician under supervision’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 must inform the Registrar in a timely manner before withdrawing Supervision

Qualifications and Characteristics of an Acceptable Supervisor

The College holds the authority to approve or decline a Supervisor, and an approval process must occur following the policy “Approval of Supervisors for College-directed Supervision”.2 Depending on the circumstances, the College may direct the supervised physician’s Sponsor and / or the relevant Health Authority to nominate potential supervisors.

Approaches to Supervision

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

Remote Supervision, including case discussions and record reviews using secure technologies, is acceptable to the College.

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

Mitigating Conflicts of Interest Between a Supervisor and a Physician under Supervision

Disclosure of a pre-existing relationship between supervisor and physician under supervision:

• The supervisor and the physician must disclose to the College any pre-existing relationship. The College. 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 assess the 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 the physician under supervision:

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

Basis for Immediate Reporting to the College

Supervisors review patient care in the course of their duties. Instances may arise where the Supervisor’s approach to care differs from that of the physician under supervision.

As a result, Supervisors may make comments on or offer recommendations intended to improve care. These recommendations are most often of a general nature and do not address any immediate or significant risk to a specific patient.

On the other end of the risk spectrum and in very rare occasions, a Supervisor may identify some deficiency in care which, if left unaddressed, may result in serious harm to a specific patient.

Similarly, in rare circumstances, a Supervisor may identify a situation in which a previously unknown and real harm has already occurred as the result of improper care. In these cases the College has outlined a procedure: Managing Patient-Care Concerns Identified During Practice Assessments³, which is intended to guide College staff and the Supervisor in addressing patient care concerns, whether of a minor or serious nature, identified in the course of their duties.

In addition, the general obligations for reporting physician health concerns or sexual misconduct by Nova Scotia physicians are laid out in College Professional Standards and Guidelines. ⁴

The Supervisor’s additional and specific obligations will be set out in the Terms of Supervision1 with the College, but generally include the requirement for the 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 Physician under Supervision is practicing outside the scope or setting approved by the College.
• the Supervised Physician’s conduct presents concern;
• the Physician under Supervision is acting in such a manner that suggests that he / she may be impaired or incapacitated;
• the Physician under Supervision fails to comply with the terms of supervision, including missing an appointment or meeting with the Supervisor without good reason, or being uncooperative;
• the 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 Supervisor becomes the subject of a complaint to the regulator, either in Nova Scotia or another jurisdiction, or;
• the physician under Supervision ceases to practice within the Health Authority.

Supervision Activities and Reports to the College

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

The Supervisor will be provided with a schedule that outlines the dates upon which his / her reports will be submitted.

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 College of Family Physicians Canada (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.

Resources Utilized in the Development of this Guideline

1. Terms of Supervision
2. Approval of Supervisors for College-directed Supervision
3. Managing Patient-Care Concerns Identified During Practice Assessments
4. CPSNS Professional Standard & Guidelines: Duty to Report Health Professionals
5. CPSNS Professional Standard & Guidelines Regarding Sexual Misconduct by Physicians