Journal of General Internal Medicine

, Volume 22, Issue 8, pp 1080–1085 | Cite as

Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety

  • Tara J T KennedyEmail author
  • Lorelei Lingard
  • G. Ross Baker
  • Lisa Kitchen
  • Glenn Regehr
Original Article



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.


To develop a conceptual model of clinical supervision to inform and guide policy and research.

Design, Setting, and Participants

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.


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”.


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.


qualitative research grounded theory methodology medical education professionalism patient safety 



The authors acknowledge the support of an operating grant from the Canadian Institutes of Health Research (CIHR). Lorelei Lingard is supported by a CIHR New Investigators Award and as the BMO Financial Group Professor in Health Professions Education Research. Glenn Regehr is supported as the Richard and Elizabeth Currie Chair in Health Professions Education Research.

Conflict of Interest

None disclosed.


  1. 1.
    Kennedy TJ, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: a tradition worth defending? Acad Med 2005;80(10 Suppl):S106–11.PubMedCrossRefGoogle Scholar
  2. 2.
    Stern RS. Medicare reimbursement policy and teaching physicians’ behavior in hospital clinics: the changes of 1996. Acad Med 2002;77(1):65–71.PubMedCrossRefGoogle Scholar
  3. 3.
    Kuttner R. Managed care and medical education. N Engl J Med 1999;341(14):1092–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ, III. Effects of limited work hours on surgical training. J Am Coll Surg 2002;195(4):531–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Charap M. Reducing resident work hours: unproven assumptions and unforeseen outcomes. Ann Intern Med 2004;140(10):814–5.PubMedGoogle Scholar
  6. 6.
    Romanchuk K. The effect of limiting residents’ work hours on their surgical training: a Canadian perspective. Acad Med 2004;79(5):384–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Matz R. Errors in medicine. Lancet 1999;353(9161):1365.PubMedCrossRefGoogle Scholar
  8. 8.
    Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J 2004;170(11):1678–86.CrossRefGoogle Scholar
  9. 9.
    Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995;163(9):458–471.PubMedGoogle Scholar
  10. 10.
    Sox CM, Burstin HR, Orav EJ, et al. The effect of supervision of residents on quality of care in five university-affiliated emergency departments. Acad Med 1998;73(7):776–82.PubMedCrossRefGoogle Scholar
  11. 11.
    Velmahos GC, Fili C, Vassiliu P, Nicolaou N, Radin R, Wilcox A. Around-the-clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients. Am Surg 2001;67(12):1175–7.PubMedGoogle Scholar
  12. 12.
    Fallon WF, Jr., Wears RL, Tepas JJ, III. Resident supervision in the operating room: does this impact on outcome? J Trauma 1993;35(4):556–60.PubMedCrossRefGoogle Scholar
  13. 13.
    Bell BM. Supervision, not regulation of hours, is the key to improving the quality of patient care. JAMA 1993;269(3):403–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Grant J, Kilminster S, Jolly B, Cottrell D. Clinical supervision of SpRs: where does it happen, when does it happen and is it effective? Specialist registrars. Med Educ 2003;37(2):140–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Coates J. The supervision of junior doctors. N Z Med J 2002;115(1151):170.PubMedGoogle Scholar
  16. 16.
    Kachalia A, Studdert DM. Professional liability issues in graduate medical education. JAMA 2004;292(9):1051–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Pope J. Even top hospitals make mistakes. 2003. The Associated Press.
  18. 18.
    AAMC policy guidance on graduate medical education: assuring quality patient care and quality education. Acad Med 2003;78(1):112–6.Google Scholar
  19. 19.
    The Royal College of Physicians and Surgeons of Canada. General Standards of Accreditation. 2002.
  20. 20.
    Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Med Educ 2000;34(10):827–40.PubMedCrossRefGoogle Scholar
  21. 21.
    Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine Pub Co., 1967.Google Scholar
  22. 22.
    Kennedy TJT, Lingard LA. Making sense of grounded theory in medical education. Med Educ 2006;40(2):101–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2 ed. Thousand Oaks: Sage Publications, 1998.Google Scholar
  24. 24.
    Corbin J, Strauss A. Grounded theory research: Procedures, canons, and evaluative criteria. Qual Sociol 1990;13(1):3–21.CrossRefGoogle Scholar
  25. 25.
    Morse JM. The significance of saturation. Qual Health Res 1995;5:147–149.CrossRefGoogle Scholar
  26. 26.
    Hammersley M, Atkinson P. What is Ethnography? Ethnography: Principles in Practice. London: Routledge, 1995.Google Scholar
  27. 27.
    Hammersley M, Atkinson P. Ethnography: Principles in Practice. 2 ed. London: Routledge, 1995.Google Scholar
  28. 28.
    Holden JD. Hawthorne effects and research into professional practice. J Eval Clin Pract 2001;7(1):65–70.PubMedCrossRefGoogle Scholar
  29. 29.
    Kelle U. Computer-Aided Qualitative Data Analysis: Theory, Methods, and Practice. Thousand Oaks, CA: Sage, 2002.Google Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Tara J T Kennedy
    • 1
    • 2
    • 3
    Email author
  • Lorelei Lingard
    • 2
    • 3
  • G. Ross Baker
    • 4
  • Lisa Kitchen
    • 3
  • Glenn Regehr
    • 3
    • 5
  1. 1.Bloorview Kids RehabTorontoCanada
  2. 2.Department of PediatricsUniversity of TorontoTorontoCanada
  3. 3.Wilson CentreUniversity Health NetworkTorontoCanada
  4. 4.Department of Health Policy, Management, and EvaluationUniversity of TorontoTorontoCanada
  5. 5.Department of SurgeryUniversity of TorontoTorontoCanada

Personalised recommendations