MGH Policy: Criteria for Concurrent Staffing of Two Operating Rooms 1. This policy is designed to ensure the highest quality and safest care for all patients undergoing an operation at MGH. 2. Every patient in the OR must have at least one attending surgeon clearly designated. 3. The attending surgeon will inform the operating room team during the preoperative huddle, either in person or by telephone, as to the surgical plan and his/her availability or the availability for another attending surgeon for the entirety of the case. This may include fellows as per Partners Policy on Resident Supervision1. 4. The attending surgeon should actively participate in the performance of each case. This will require the attending surgeon to "scrub" parts of each case, with well-defined exceptions, such as endoscopic procedures. 5. It is expected that at times when a surgeon is scheduled in concurrent rooms, that he or she be in the OR and not in clinic or their office. 6. In cases in which the primary surgeon is participating in a second case or is not readily available, another surgeon must be designated as being available2. 7. It is recognized that there may be circumstances, such as simultaneous emergency cases when on call, in which a surgeon may make an exception to having a second designated surgeon available. 8. The involvement of the attending surgeon will be discussed with each patient and their family to the extent felt appropriate by the attending surgeon. Suggested discussion points: -Provision of care is by an entire team, including trainees. -Attending surgeon will oversee the care by the team. -Attending surgeon will participate in all critical components of the case. -Attending surgeon may not be present during non-critical portions of the case, but the surgeon’s associate will be providing coverage during such times. -Attending surgeon may not perform or be present in the room for the entire case, however, will be immediately available or have another surgeon available. 9. The allocation of simultaneous elective blocks will be at the discretion of Division/Department Surgical Chiefs with consideration of all billing compliance regulations, quality and efficiency of OR performance, experience of training in staffing two simultaneous operating rooms of the individual surgeon and appropriate assistant availability. 10. The performance of surgeons staffing two rooms simultaneously will be reviewed quarterly as to adherence to these guidelines. 11. Service leadership will be instructed to establish a definition of the "critical components" of most standard operative procedures on their service, as well as defining operations and patient conditions when overlap of operative procedure is not appropriate. These definitions should be maintained by the service chief. 12. Three simultaneous cases as the primary surgeon are not allowed under any circumstances. 13. It is understood that all activities related to concurrent staffing of two operating rooms will be compliant with existing Medicare rules for overlapping cases. # 1 Partners Policy- Resident Supervision The following provisions apply to all Graduate Medical Education (GME) training programs sponsored by the Brigham and Women’s and Massachusetts General Hospitals. Further, this policy applies to all residents when assigned to any other institution or clinical site as part of their GME program. The term “resident” in this document refers to interns, specialty residents and subspecialty clinical fellows enrolled in any GME program.  Residents will treat patients only under the supervision of staff attending physicians who are independently licensed and duly credentialed by the institution. Each patient will be assigned an attending physician of record who is responsible for his/her care and for determining and implementing the appropriate level of supervision of the resident.  Patients shall be notified of the name of the attending staff physician responsible for their care, that residents participating in their care are supervised by such staff physician(s) and of the respective roles of the residents and faculty members involved in their care.  The supervising physician’s involvement in a patient’s case, and all members of the health care team of attending physicians and residents responsible for each patient’s care, shall be documented in the medical record.  In providing clinical supervision to residents, the attending staff physician shall liberally provide advice and support, shall encourage residents to freely seek their input and should delegate portions of care to residents, based on the residents' skills and the needs of the patient.  The faculty must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities, and to demonstrate a strong interest in the education of residents.  Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility.  Residents are expected to make liberal use of the supervisory resources available to them and are encouraged to seek advice and input from the attending staff physician and more senior residents, as appropriate.  Each resident's clinical responsibilities will be based on PGY-level and resident education; patient safety and severity and complexity of patient illness/condition; and available support services.  PGY-1 residents should be supervised either a) directly or b) indirectly with direct supervision immediately available.  Additional guidelines regarding supervision of residents shall be developed by individual departments and/or training programs that are in accordance with the ACGME Common Program Requirements and their respective RRC Program Requirements. These guidelines should include specific information regarding the following:  the achieved competencies (as defined by the respective RRC) under which PGY-1 residents progress to indirect supervision with direct supervision available, if applicable  the limits of the residents' scope of authority, and the circumstances under which they are permitted to act with conditional independence, using the following classification of supervision:     direct supervision: the supervising physician is physically present with the resident and patient indirect supervision with direct supervision immediately available: the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide direct supervision indirect supervision with direct supervision available: the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide direct supervision oversight: the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.  circumstances and/or events that residents must communicate to appropriate supervising faculty members, such as the transfer of a patient to another or an intensive care unit or end-of-life decisions  whom the resident should call for back-up in the event that a) patient volume or acuity becomes greater than s/he can appropriately handle, b) s/he becomes ill while on duty or experiences fatigue interfering with performance, or c) otherwise is unable to perform his/her patient care duties  Program directors will monitor resident supervision at all sites participating in the program.  At least annually, a report shall be made to the Board of Trustees of the Hospital regarding the activities of the residents and GME training programs. Note: Some physicians may hold simultaneous appointments as a clinical fellow and as a member of the attending staff. This policy applies to those individuals when they are acting within the scope of their fellowship responsibilities, and not in their attending role. Approved by the Partners Education Committee 4/11/11 Effective: 7/1/11 Amended: 10/31/11 # 2 Policy on Surgeon Immediate Availability* The Surgical Coordinating Committee reviewed the existing MGH policy for presence and immediate availability of the responsible staff surgeon during surgical procedures on patients for whom they submit a professional fee and to provide appropriate supervision of patient care. The Committee agreed on the following definition of “Immediately Available”: The surgeon will remain within the main campus of the Massachusetts General Hospital and will be able to return to the Operating Room in a timely manner whenever he/she is responsible for surgical care of a patient in the operating room. Within the discussion it was determined that the Massachusetts Eye and Ear Infirmary and the Shriner’s Burn Institute, offices at Charles River Park are considered to be part of the campus of MGH. * Updated February, 2012