Procedure Certifications
As outlined in the Case and Procedures Management Policy, the GME Institutional Supervision and Accountability Policy defines levels of supervision for residents, including supervision of procedures. Each program must develop its own program-specific supervision policy that includes a comprehensive list of each clinical activity or procedure with the appropriate level of supervision for each PGY-level.
Per Joint Commission and ACGME CLER requirements, clinical staff must be able to verify individual trainees’ required supervision level for each procedure to ensure patient safety. This information should be made available via the Resident/Fellow Procedure Certifications tool within MedHub’s GME Job Descriptions and should be updated semi-annually. To assist programs in populating the tool with accurate and timely information about each trainee, we have provided instructions below.
Procedure certification is a separate process that does NOT impact how resident/fellow procedures and cases are logged. Programs should continue to log cases and procedures in the ACGME Case Log or at the National Society or Specialty Boards site that is currently used.
The MedHub Procedure Certification process overview was provided at the May 19, 2022 Lunch & Learn. Please see the video recording and slides.
Procedure Certification Module
Below is a series of instructions and short videos that will guide you through setting up and maintaining procedure certifications for each of your trainees.
Resident/Fellow Procedure Certifications page
This video provides a brief overview of the Resident/Fellow Procedure Certifications page and explains how it is used.
Navigating to the Procedure tab in MedHub
Step-by-Step Instructions
| Login to MedHub |
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| Click on the Procedures tab |
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If you are directed to the MedHub Procedures tool, skip to “Enabling Supervision Levels” below.
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| If the Procedures tab sends you outside of MedHub to ADS, follow these instructions to create a permanent shortcut for easily accessing the Procedures tab: |
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| Hover over “Account” and click “User preferences” |
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| Check “Enable Favorites Button”. Click “Update Preferences” |
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| Once enabled, a star will appear to the right of your name. Click on the star and select “Manage Favorites” |
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| Select “Add Custom Link” |
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| Input Link Title: “Procedures” and Link URL: “https://uw.medhub.com/u/a/procedures.mh” |
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| Once activated you will see the “Procedures” link in the star menu. To navigate to the MedHub procedures tool at any time, select the star and then Procedures. |
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Enabling Supervision Levels
The below steps show how to enable levels of supervision for procedures in MedHub. This must be done before procedure certification setup can proceed.
Note: Enabling supervision levels will overwrite any existing procedure certifications.
If your program currently uses the MedHub procedure certification tool, see the Running Procedure Certification Reports section of this page for guidance on downloading all procedure certification data so that it can be translated into the new format (for current trainees) or saved outside MedHub (for alumni records).
Step-by-Step Instructions
| From the MedHub homepage, navigate to Program Settings |
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| Select the Procedures tab |
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| Change the setting for “Certify Residents for Procedures” to “Enabled – Levels of Supervision”. Click “Save Settings”. |
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| This popup will appear. Supervision levels are actually defined at the institution level in MedHub, so this message can be disregarded. Click “OK”. |
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Defining the Procedures
Any procedures listed in the “Levels of Supervision for Common Specialty Clinical Activities and Invasive Procedures” section of your program supervision policy should be added to the MedHub Procedure Type List.
This video focuses only on procedure certification. For instructions on setting up procedures for your trainees to log procedures in MedHub, go to the MedHub Help tab and search for “procedures” to find instructional videos and documentation.
Certifying Trainee Procedures
Per the GME Institutional Supervision and Accountability Policy programs must determine the required level of supervision for each procedure for individual trainees as they progress from direct supervision to independent clinical practice.
ACGME has defined the supervision levels as follows:
- Direct Supervision
- Direct Supervision with supervisor physically present
- Direct Supervision with supervisor monitoring patient care through telemedicine (if allowable in your Specialty-Specific requirements)
- Indirect Supervision
- Oversight
Programs must follow the instructions below to define the required level of supervision for each trainee in MedHub based on their supervision policy and on each individuals’ knowledge and skills, as determined by the Program Director and the Clinical Competency Committee (CCC).
Certifying Procedures by Batch
| Step-by-Step Instructions | |
| Navigate to the Procedures tab |
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| Select “Procedure Certifications”. |
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| Click “Batch Certify by Level”. |
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| Select the appropriate supervision level for each procedure type for each training level. Click “Batch Update Certifications.” |
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Certifying Procedures for an Individual
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| Navigate to the Procedures tab |
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| Select “Procedure Certifications”. |
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| Select a resident to certify |
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| Select the appropriate supervision level for each procedure type for the selected resident. Click “Update Certifications”. |
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Instructional Video
Running Procedure Certification Reports
This report will export all procedures certified by your program.
Step-by-Step Instructions
| Navigate to the Procedures tab |
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| Click “Export Procedure Certifications” |
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| A file containing all procedures that have ever been certified for residents in your program will automatically export. |
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Optional: Trainee-specific Procedure Certification URLs
Some programs may want to provide an easy way for healthcare providers to access trainee-specific required level of supervision. Follow the instructions below to find a URL for each trainee’s list of certified procedures.
Step-by-Step Instructions
| Go to the Resident/Fellow Procedure Certifications tool | |
| From the Browse section, select your program. Click Submit |
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| Hover over a name. Right click > Copy Link Address, or open each in a new tab and copy URL from the address bar. |
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| Save the individual URL for each trainee in the program to a list. |
FAQs
Does my program need to log procedures in MedHub?
No. The procedure certification tool makes visible to healthcare workers the “Levels of Supervision for Common Specialty Clinical Activities and Invasive Procedures” defined by each program’s Supervision Policy, as they apply to individual residents and fellows they are working with. Procedures should be logged as normal at the ACGME Case Log, National Society or Specialty Boards site used by your program. If your trainees perform procedures, your program should participate in this process, but your trainees do not need to change their method of logging procedures.
What if trainees in my program do not perform procedures?
If your trainees don’t perform procedures, this process does not apply.
How frequently should I update my trainees' certification in MedHub?
At a minimum, programs should update procedure certifications for each resident or fellow semi-annually at the mid (November/December) and end of academic year (June/July).
When should I use Batch Certification?
It is recommended that only programs with multiple trainees use Batch Certification at the start of their first year in your training program (i.e. R1). As the trainee progresses in independence, it is advisable that programs certify individually to reflect each trainee’s progress.
Does Batch Certification mean I can only certify trainees by level?
No. You can use Batch or Individual Certification. Batch Certification is a tool to assist you in updating large amounts of data. Procedure certification levels should follow your program’s Supervision Policy. Please note, using Batch Certification will overwrite any existing procedure certifications (see Running Procedure Certification Reports for instructions on downloading reports prior to overwriting past records).
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Are Procedure Logs impacted by batch or individual certification?
No. Procedure Logs are a separate tool within MedHub and are not impacted by the Procedure Certification process.
Are alumni procedure certifications impacted?
Yes. Converting to Supervision Levels will wipe out Alumni procedure certifications. Programs are advised to download the “Export Procedure Certifications” report and save it outside of MedHub for future certification reporting needs (see Running Procedure Certification Reports instructions).
Can a trainee be automatically certified in MedHub for a particular procedure after logging a certain number of procedures?
No. There is not a way to automate certification using supervision levels in MedHub. Manual advancement of supervision levels is required as there are four levels of supervision to choose from.
Who has access to Procedure Certifications?
Anyone with a link to the Resident/Fellow Procedure Certifications tool. It will be primarily used by nurses and other healthcare providers who work with your trainees in clinical settings. This tool is available to UW Medicine Clinical staff via the UW Clinical Toolkit, and may be linked on other hospital websites as well.
What if my program has previously used the Procedure Certification module?
If your program has been using this tool, you will still need to follow the steps on this page, but you should back up your procedure certifications before beginning to make sure no data is lost. Do this by selecting “Export Procedure Certifications” from the Procedures tab. See the “Running Procedure Certification Reports” section on this page for more details.
How do I update my program's Supervision Policy?
See instructions on the Program Supervision Policies page.
How can I get the word out about my trainee's list of certified procedures?
Some programs have created individualized QR code stickers from the trainee-specific URL. Trainees can place the QR code on the back of one of their badges allowing healthcare providers to scan for direct access to that trainee’s procedure certification list.