Clinical oversight: Conceptualizing the relationship between supervision and safety

Background: Concern about the link between clinical supervision and safe, quality health care has led to widespread increases in the supervision of medical trainees. The effects of increased supervision on patient care and trainee education are not known, primarily because the current multifacted and poorly operationalized concept of clinical supervision limits the potential for evaluation. Objective: To develop a conceptual model of clinical supervision to inform and guide policy and research. Design, Setting, and Participant: Observational fieldwork and interviews were conducted in the Emergency Department and General Internal Medicine in-patient teaching wards of two academic health sciences centers associated with an urban Canadian medical school. Members of 12 Internal Medicine and Emergency Medicine teaching teams (n=88) were observed during regular clinical activities (216 hours). Sixty-five participants (12 physicians, 28 residents, 17 medical students, 8 nurses) also completed interviews about supervision. Field notes and interview transcripts were analyzed for emergent themes using grounded theory methodology. Results: The term clinical oversight was developed to describe patient care activities performed by supervisors to ensure quality of care. Routine oversight (preplanned monitoring of trainees' clinical work) can expose supervisors to concerns that trigger responsive oversight (a double-check or elaboration of trainees' clinical work). Supervisors sometimes engage in backstage oversight (oversight of which the trainee is not directly aware). When supervisors encounter a situation that exceeds a trainee's competence, they move beyond clinical oversight to direct patient care. Conclusions: This study elaborates a typology of clinical oversight activities including routine, responsive, and backstage oversight. This new typology provides a framework for clinical supervision policy and for research to evaluate the relationship between supervision and safety.