Introduction

Ensuring quality care and safety for your registrar’s patients is primarily the responsibility of the supervisory team and training practice. You are responsible for the registrar’s safety as they consult. The RACGP vocational training standards require the level of registrar supervision to be matched to the registrar’s level of competence.

A registrar who is capable of consulting safely without review of every patient encounter is said to be at Foundation Level. A registrar at Foundation Level has the clinical knowledge, skills, and attitudes to assess common general practice presentations and has insight into the limits of their competency and accesses help when required. They can practice safely provided they have reliable access to supervisory support and close oversight of their practice. A ‘Clinical Supervision Plan’ details how the supervision will be provided.

For registrars in their first term, the RACGP has developed a suite of activities called the Early Assessment for Safety and Learning (EASL) to help you assess your registrar's readiness to practice at Foundation Level and to help you develop their ‘Clinical Supervision Plan’. For registrars commencing in later terms, the development of the ‘Clinical Supervision Plan’ will be informed by assessments in previous terms and discussions you have with them during orientation to the practice.

The clinical supervision plan describes how your practice intends to provide safe supervision when your registrar is not having review of every consultation. It is an important document for the registrar and for all members of your practice supervision team. A new clinical supervision plan needs to be developed for every registrar term as registrar competencies are different for each registrar, registrar competency changes over time, and practice circumstances may change from term to term.

A clinical supervision plan addresses three things: 1) when to call for help; 2) who to call for help; and 3) how to call for help. In this document we will outline the issues to consider in addressing each of these and recommend how the plan should be reviewed. We then provide a template for you to complete with your registrar.

When to call for help

To help inform this discussion your registrar should be provided with the ‘call for help’ list – a document that lists problems that registrars and supervisors have considered likely to warrant a call for help. Ask your registrar to complete a self-assessment of their confidence to manage the clinical problems on the list. This self-assessment, combined with any other available assessments and your knowledge of your registrar’s previous experience should inform a conversation about when they should call for help.

You may wish to continue to use the ‘call for help’ list as a checklist, ticking off each scenario as you determine it can be safely managed, but the expectation is that most practices will just use the list as a ‘conversation starter.’

Who to call for help

A registrar must know who to call for help. There is not one correct way of allocating responsibility for supervision. Some practices have the registrar always calling the same supervisor, others operate on a supervisory on-call roster. Some practices identify doctors to be called for specific clinical problems (skin expert, women's health etc). Whatever method is chosen, it should be documented and clearly communicated to everyone involved.

Once there is no longer review of every consultation, the most crucial factor for effective supervision is that the supervisor is ‘approachable and available.’ It is important that the supervisor of first contact allows time in their appointment schedule for the predictable interruptions, particularly early in the placement. A backup plan needs to be recorded for when the first-call supervisor is unable to assist or unable to assist immediately. This avoids jeopardizing patient safety when a registrar cannot obtain the help they need and ensures efficient operation of your practice.

Other circumstances that may need to be considered include supervision for hospital inpatient care or after-hours care. If members of your supervisory team have planned leave, the covering arrangements should be documented. If you have concerns about your ability to provide appropriate cover throughout the whole term your local training coordinator should be contacted.

How to call for help

How to call for help will also differ between practices, so this needs to be documented for your practice. Most supervisors will prefer a phone call, but others will use instant messaging systems or a knock on the door.

Your registrar may need some guidance about how to explain their call for help to their patient. As we do not want to undermine the patient’s confidence in their registrar, it may be best for the registrar to explain their call for help as requesting a ‘second opinion’.

It is also worth spending some time educating your registrar about how you would like requests for help to be communicated to you. For example, you may instruct your registrar to first identify whether they are going to need advice without you seeing the patient or if they need you to come into their room, and the degree of urgency involved. Once this is established the next steps can be negotiated. This is discussed in greater detail in Module 4 of the Foundations of GP Supervision course in gplearning.

Reviewing the clinical supervision plan

It is important to regularly review the clinical supervision plan. It will likely need to change as your registrar progresses through the term or if practice circumstances change. It is also important that you periodically audit a sample of the registrar’s records to detect if a registrar is failing to call you when they should. This can occur for several reasons including:

a registrar embarrassed to reveal what they do not know

a registrar feeling their interruption would be unwelcome or a major inconvenience

a registrar perceiving that the supervisor does not have the required expertise

a registrar not recognising when they needed help. The so-called ‘unknown unknowns’ we all have.

The most used strategy for auditing registrar consultations is Random Case Analysis (RCA). RCA involves reviewing with the registrar a sample of recent records and is usually conducted during a scheduled teaching session. Alternative options to RCA include reviewing the notes and only discussing those of concern with your registrar, conducting a review of specialist referrals, or an ‘inbox audit’ of pathology and imaging results. All these strategies may detect circumstances where a registrar failed to seek help from their supervisor.

Clinical supervision plan

A supervisor should complete this document with their registrar following the orientation period in each term. The supervisor first needs to be satisfied that the registrar does not require review of all their consultations. The plan will need reviewing and revising as the registrar progresses.

Practice name

Registrar name Date of plan

Primary supervisor name

Stage of training

Other members of the supervisory team

Name	Role
Other accredited supervisors
Allied health staff
Admin and reception staff

When is the registrar expected to call for help?

Document the particular presentations or circumstances when you expect the registrar to call for help. Are there situations where help can be sought at the end of the session rather than at the time of the consultation? The registrar should be encouraged to call for help whenever they feel unable to adequately meet the patient’s need.

Who is to be called for help?

Record the current arrangements for who the registrar should call during each session and document what should happen when the first-call doctor is not available. This may include arrangements for after-hours and hospital on-call back up. If there are multiple supervisors, you may wish to use a supervision roster, like the example below.

Supervision roster (For each session who should the registrar call, and what back-up is available)

Days	AM	PM	After hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Leave cover

If there is planned leave by members of your supervisory team during the term, how will this be covered?

How should a call for help be made?

Via phone, knock on door, IT messaging? Consider how will it be explained to the patient and how the request for help should be articulated.