Education is one of VA’s four core missions, and in fiscal year 2002, VA paid approximately $383 million to residents training at about 130 VA health care facilities. For the 2002/2003 academic year, VA supported almost 8,800 residency slots, about 9 percent of all residency training positions in the United States. Moreover, because several residents typically rotate through each slot, VA estimates that it provides graduate medical training to more than 28,000 residents each year, or as many as one-third of the nation’s residents. The number of residency slots VA allocates to individual medical centers involved in GME ranges from less than 1 to more than 200. Although about half of VA’s residency positions are in primary care, VA supports GME in 45 recognized medical specialties and subspecialties; individual medical centers provide training in from 1 to more than 30 specialties. VA headquarters officials have ultimate oversight responsibility for the activities of residents within VA medical centers, and several different headquarters offices have monitoring functions that relate to resident supervision. VA’s Office of Academic Affiliations (OAA) has responsibility for developing and overseeing policies for resident supervision, monitoring VA’s GME activities, and allocating residency slots. Under the Patient Safety Program VA implemented in January 2002, VA’s National Center for Patient Safety collects and analyzes information from VA medical centers about patient risk events and their causes. Medical centers are required to report all patient safety events—including adverse events and close calls—to the National Center for Patient Safety. In addition, medical centers are required to determine the root causes of patient safety incidents with severe or potentially severe outcomes and develop plans to prevent them in the future. The success of this program will depend on the extent to which VA is able to establish a culture in which employees feel safe to make these reports. VA’s Office of Patient Care Services establishes and monitors health care programs. For example, its National Surgical Quality Improvement Program (NSQIP) examines postoperative outcomes. Additional oversight of resident supervision is provided by VA’s Office of Inspector General. Because VA’s health care system is decentralized, responsibilities for implementing VA’s national policy for resident supervision are assigned to networks and medical centers. Network officials are to provide medical centers with the resources necessary to ensure that residents are supervised in accordance with VA’s national policy and are to evaluate the strengths and weaknesses of medical centers’ GME activities. Medical center directors are responsible for establishing facility policies for resident supervision that fulfill the requirements of VA’s national policy, and medical center chiefs of staff are responsible for the educational and patient care activities of all residents within the facility. In addition, a physician in each medical specialty is responsible for ensuring that the residents training in that specialty are supervised as required. VA medical centers typically also share responsibility for the oversight of residents with affiliated institutions that sponsor GME programs. VA participates in more than 1,900 distinct GME programs, 29 of which are sponsored by VA medical centers. The rest are sponsored by about 120 medical schools and teaching hospitals with which VA medical centers are affiliated. The majority of VA medical centers work with one GME sponsoring institution, but individual VA medical centers participate in the GME programs of up to four different sponsors. When a VA medical center serves as a training site for residents, but is not the sponsoring institution, it is known as a participating institution. GME accrediting bodies hold sponsoring institutions responsible for all aspects of their educational programs, including aspects conducted within participating institutions. GME accrediting bodies do not separately accredit participating institutions and do not evaluate the extent to which supervision that occurs within participating institutions, such as VA medical centers, meets requirements set by those participating institutions. VA requires accreditation of each GME program through which its residents obtain training. More than 98 percent of VA’s residency slots are filled by residents in GME programs that are subject to accreditation review by the Accreditation Council for Graduate Medical Education (ACGME); the remaining slots are filled by residents in osteopathic programs that are subject to accreditation review by the American Osteopathic Association. GME accreditation status indicates an overall assessment of the quality of an educational program in a particular medical specialty. Accrediting bodies evaluate several aspects of each GME program, including provisions for the supervision and safety of residents, the adequacy of institutional resources, educational curriculum, and the extent to which the program meets that specialty’s specific training requirements. A program can be fully accredited, or a program can be granted accreditation with notification of problems that must be corrected. Accreditation can also be withdrawn. A program’s accreditation status is made public, but to safeguard confidential information, specific problems with the program or its training sites are described in letters sent only to the sponsoring institution. Accrediting bodies have not been sending these letters to participating institutions. Accrediting bodies state that the quality of patient care must remain the highest priority of GME programs. Health care organizations that provide GME must ensure that qualified staff physicians supervise residents and that the same standards for the quality and safety of patient care apply when residents are involved in health care delivery as when they are not. GME accrediting bodies require that supervising physicians adjust the level of supervision to meet the educational goal of increasing residents’ competence by giving them appropriate opportunities to assume greater independence in their patient-care activities, that is, allowing residents to assume graduated responsibilities. The supervising physician relies on his or her professional judgment and knowledge of the patient’s medical condition and the resident’s level of mastery to determine the degree of independence of the resident’s patient-care responsibilities. VA’s national policy on resident supervision is detailed in a handbook that establishes specific requirements for (1) the involvement of supervising physicians in the care provided by residents who diagnose, treat, or discharge patients and (2) the documentation of that involvement. These specific requirements apply to four domains of residents’ clinical activity—inpatient care, outpatient care, diagnostic and therapeutic procedures, and consultations—and provide guidelines for putting into practice GME accrediting bodies’ principles of resident supervision and graduated levels of responsibility. (See table 1 for an example of VA’s requirements for supervision in each of the four domains.) Experts on GME told us that the requirements in VA’s handbook are reasonable and appropriately consider the role of supervision in ensuring the quality of patient care and of resident education. Some of these experts described it as a best practice model. VA does not have adequate procedures to determine whether residents at VA medical centers are supervised in accordance with its national requirements. For example, VA does not check whether each medical center involved in GME has adopted policies that are consistent with VA’s requirements for resident supervision. To learn what medical centers and networks do to monitor whether supervision is consistent with VA’s national requirements, VA requires that medical centers and networks submit annual reports on residency training. Medical centers’ reports filed for the 2000/2001 academic year indicate that most medical centers review some documentation of resident supervision, but few conduct comprehensive reviews. To obtain more complete information about the supervision residents receive, VA is planning to use external peer review to assess adherence to its requirements for documenting resident supervision. These plans have not been finalized. For example, as of May 2003, VA had not decided whether reviewers would examine records from VA’s new outpatients. VA does not know whether all its medical centers have adopted policies that are consistent with the specific requirements in its resident supervision handbook for the supervision of residents’ diagnosis, treatment, and discharge of patients. The director of each medical center involved in GME is to establish facility policies for resident supervision that fulfill the requirements in VA’s handbook, but VA requires a review of only one requirement involving the supervision of diagnostic and therapeutic procedures—the medical centers’ requirements for the minimal acceptable level of supervision for diagnostic and therapeutic procedures. Specifically, in situations in which the supervising physician is not in the operating or procedural suite, VA requires that the supervisor must, at a minimum, be immediately available in the facility or campus to provide direct supervision of the procedure if necessary. Network GME managers are supposed to review and approve this requirement; they are not required to report the results of their reviews to OAA. There is no separate OAA review of any of the requirements in medical centers’ supervision policies. We found that not all networks have completed the one required review and that medical centers’ policies are not always consistent with VA’s national policy. Of the 11 network GME managers we interviewed, 7 told us that they had completed this required review of the minimal requirements for supervision of procedures in medical center policies, but 4 told us that they had not. We found that the requirement of a medical center in one of the four networks that had not conducted this review was less stringent than the requirement in VA’s handbook for supervision of diagnostic and therapeutic procedures. The written policy at this medical center stated that the supervising physician can be immediately available by telephone rather than requiring him or her to be immediately available in the facility or on campus. One network GME manager who did review this requirement for supervision of diagnostic and therapeutic procedures told us that in 2002, he identified three medical centers that had written requirements for supervision of these procedures that were less stringent than the requirement in VA’s handbook and that he instructed each of these facilities to change its policy to be consistent with VA’s national requirement. To learn what medical centers and networks do to monitor whether supervision is consistent with VA’s resident supervision handbook, VA has required annual reports on residency training programs beginning with the 1999/2000 academic year. Medical center managers are to provide narrative answers to specific open-ended questions about their monitoring processes as well as about the problems they identified and actions they took to address them for each of three areas of oversight. (See table 2.) These medical center reports are channeled through VA’s networks to OAA.