PATIENT CARE MEMORANDUM-11-066-LM                                          MARCH 2015





1.   PURPOSE:  To establish policy and procedures for the presence of healthcare professional clinicians (physicians, dentists, nurses, psychologists,                pharmacists, etc.), healthcare professional researchers, and healthcare professional guests (including trainees of any type) in inpatient, outpatient,          and research areas of the VA Boston Healthcare System (VABHS), when their only activity is observation. 

2.   POLICY: 


       a.   Periodically, clinical and research services and/or individuals may wish to accommodate healthcare professionals or trainees who visit and                         serve as educators, observers, or learners, but who may lack US or Massachusetts licensure, and who may also lack credentials or privileges at                 this facility.

       b.   These individuals do not fall under the province of formal undergraduate, residency, or other trainee education; or they may be fully licensed                    healthcare professionals with privileges at other institutions, but who lack them at VABHS. 

       c.   They may include trainees of any type 18 years or older who have graduated from high school (or the international equivalent) from                                     institutions that are unaffiliated with VABHS who wish to observe only, for a limited period of time.

       d.   They may include researchers 18 years or older who have graduated from high school (or the international equivalent) who wish to observe                       only, for a limited period of time.


       e.   Observation is at the discretion of the particular clinical service, section, and individual who chooses to have an observer. VABHS allows                               observer activity with certain rigorous guidelines. The Chief of Staff, or designees including but not limited to the Associate Chief of Staff for                       Education (ACOS-E), Associate Chief of Staff for Research (ACOS-R), and Deputy Chief of Staff, are the approving officials for clinical and                                 research  observers.  The driving principles behind this policy are patient safety, patient privacy and confidentiality, and minimization of risk.                     Observers have no clinical or research standing at the medical center.  They are not covered by the Federal Tort Claims Act. Clinical, research,                     or any other activity besides observing is prohibited. All clinical, research, or other activities performed by a clinical observer carry the risk of                     individual personal liability and thus are prohibited. 

             (1)   Acceptance of any candidate for a clinical or research observership shall be based on individual qualifications, program and educational                              resources, and availability of space, and in no way establishes precedence for further requests.  Observerships generally last between a                              few hours to a few days, but may be as long as six (6) months and may be renewed; the rationale for any renewal must be clearly                                          delineated.

                    (a)   Examples of observers who may wish to stay for a longer period of time include (i) the college or post-college student who needs                                         observation hours prior to applying for a healthcare professional training program, such as physician assistant and physical therapy                                     programs, both of which may require observation hours. For example, one Boston physician assistant program recommends 250 to 500                             hours of observation; (ii) the international medical graduate (IMG) who requires 3-6 months of observation in the USA prior to applying                               to a USA residency; (iii) the student or provider visiting from another country for a semester observing a VABHS provider; and (iv) the                                   visiting researcher who is observing for a semester.

                    (b)  In these longer observerships the individual may be present in the medical center daily or just occasionally throughout the observation                               period. For example, the observer may be allowed to observe for 6 months but may only be present once a week or once a month                                       during that 6 month period.

             (2)   No student, resident, or other trainee from a VABHS affiliate shall be displaced by these observers. No educational credit or critique shall                             be provided for this experience, other than observation hours. The presence of observers shall not compromise clinical, research, or                                   administrative space. A letter stating that the observer was present may be written, and may indicate the number of hours observed. A                               letter of reference or recommendation may also be written. There is no salary or benefits associated with an observership. Provisions for                           lodging, travel, transportation, visas, and living expenses shall be the responsibility of the individual. Any candidate may be dismissed from                         the experience at any time by the sponsoring individual or an institutional official, without due process. 

             (3)   Clinical and Research Observers may include the following individuals:    

                     (a)   International Medical Graduates (IMGs) who have received an M.D. degree from an international medical school, but have not received                                any United States residency training, and are not currently enrolled in a residency program.  These IMGs cannot be licensed in the USA                                at this stage of their training and would qualify for clinical observer status.

                     (b)   IMGs who have received an M.D. degree from an international medical school, and have not received any United States residency                                         training, but have been accepted into a residency program pending 3-6 months of clinical experience.  These IMGs cannot be licensed                                 in the US at this stage of their training and would qualify for clinical observer status.

  1. IMGs who have received an M.D. degree from an international medical school, may be licensed in their own country, but unlicensed in the USA.   

  2. American Medical Graduates (AMGs) who are switching residency programs and are in a transition period, but are not currently enrolled in an accredited residency program should be considered clinical observers during the transition between residency programs.

  3. Certain AMGs who have completed a residency program may not be licensed because they did not pass Step 3 of the USMLE.  Although these individuals have completed their education and training, their inability to be licensed may qualify them for observer status.  An AMG with less than one year of residency training would be unlicensed and also an observer.

  4. Some allied health practitioners also fall under the scope of this policy.  Allied health practitioners who are already licensed may be appointed as WOC personnel, and, therefore, may practice clinically.  Allied health practitioner trainees should always be covered under an active and valid Affiliation Agreement with the agreement signed by the ACOS-E and the Medical Center Director.  All other allied health practitioners are considered clinical observers.  This policy pertains to Physician Assistants, Nurse Practitioners, Licensed nursing personnel (LPN and RN), licensed therapists of all types (physical, kinesis, occupational, recreation), dietitians, chaplains, social workers, psychologists, and others.


  1. Other healthcare visitors including Visiting Professors, clinical educators from affiliated institutions, and others.


  1. Researchers and researchers-in-training of any type.


  1. Undergraduates, graduate students, and individuals who have completed their undergraduate degree and need observation hours for entrance into a clinical program (e.g., Occupational therapy, Physician Assistant programs) would also qualify as observers.


  1. It should be noted that observers are always accompanied by the VABHS sponsor or the designee of the sponsor, unless they are in a public area of the medical center (such as the main lobby or cafeteria). Under no circumstances would an observer ever be unaccompanied in any restricted area of the medical center, such as a laboratory or patient care area.


  1. With the exception of Visiting Professors, observers must undergo a background check and fingerprinting through human resources, and testing for tuberculosis (completed at observer’s expense) before she or he starts at VABHS.


  1. Visiting Professors are considered a special case. Visiting Professors are clinicians and/or researchers who are active at another institution. Visiting Professors have a local, national, or international reputation and/or they are known personally by the VABHS Sponsor. Because they are active at another institution and they are known by the VABHS Sponsor either personally or by reputation, Visiting Professors do not require background checks. It is assumed that Visiting Professors have up-to-date tuberculosis screening and are well-versed with regard to patient and/or laboratory safety, patient privacy and confidentiality, minimization of risk, as well as basic safety and infection control information and procedures. Visiting Professors do not need to undergo fingerprinting, prove that they have had tuberculosis screening, or review Attachment D. Visiting Professors and their VABHS Sponsors must fill out Attachment C. Visiting Professors are allowed to observe as Visiting Professor Observers one time for up to one week. Visiting Professors who wish to return for a second visit to VABHS or to stay longer than one week may utilize the regular Observer, Volunteer, or Without Compensation mechanisms.


  1. IMG observers are solely responsible for obtaining visas, and VABHS assumes no role in sponsoring or facilitating a visa for the purpose of observing.


  1. When additional activities of the individual are desired or required beyond what is allowed under this observer policy, the Volunteer or Without Compensation (WOC) employee mechanisms may be used.


  1. RESPONSIBILITY:  The ACOS-E has overall responsibility for ensuring this policy and its associated procedures are carried out in a way which ensures patient safety and minimizes disruption to our clinical care and training environments.  




a. Observers must have a VABHS sponsor for preparation and submission of the request form (Attachment A or C).  The sponsor takes full responsibility for the observer in the clinical or research environment and ensures that these guidelines are followed.  The sponsor will be responsible for providing or arranging for orientation and supervision of the observer.


b. Observers may not participate in direct patient care or research.  They may not see or interact with any patient individually without a VABHS paid or WOC employee present.  Specifically, they may not take patient histories, perform any part of a physical examination, perform procedures, initiate orders or treatments, dictate discharge summaries or operative notes, or otherwise make entries into the medical record.  Independent patient contact is absolutely prohibited.  The observer must be identified to patients, and patients must provide oral consent to their presence.


c. Observers who are engaged in patient-related activities may be asked to sign a paper acknowledging the responsibilities of confidentiality. Observers may participate in grand rounds, seminars, or other didactic activities.  They may participate in case conferences and chart rounds.  Observers may observe walking rounds with a supervising attending or senior resident.  They may view and discuss videotapes of patient evaluations, if properly authorized by patient signed consent for release of information.


d. Observers must be oriented to basic safety and infection control information and procedures.  They must be informed of and agree to comply with policies regarding patient confidentiality, information security, infection prevention, and customer service.  It is the responsibility of the VABHS sponsor to provide this orientation or to make arrangements for this orientation to occur.  Observers are NOT authorized to obtain computer codes or have electronic chart access.


e. All observers must be approved in advance with the explicit consent of the Chief of Staff or designees including, but not limited to, the Associate Chief of Staff for Education (ACOS-E), Associate Chief of Staff for Research (ACOS-R), and Deputy Chief of Staff.  Attachment A or C and required paperwork should be forwarded to the Office of the ACOS-E for clinical observation or the ACOS-R for research observation for each observer.  VABHS sponsors may submit the form on paper, by fax, or via an email containing the exact information.  A log of clinical and research observers will be kept in the ACOS-E and ACOS-R offices, respectively, as a permanent record with their starting and ending dates and sponsor’s name. 


f. If observers wish to participate in either research or clinical activities above and beyond what is allowed as an observer they should be encouraged to register as volunteers or obtain WOC appointments. 


      g. Attachment B shows required paperwork necessary for an observership.


h. Attachment C shows required paperwork necessary for a Visiting Professor observership.


i. Attachment D consists of pages extracted from the volunteer handbook that are necessary for observers to read, understand, and follow (with the exception of Visiting Professors; see paragraph 2.h.). 



OAA Guidance to Field Re: Observers, May 23, 2007.

AAMC Infolist Question "Observerships, Externships and Visiting Residents", dated 9/20/2001. 

VHA DIRECTIVE 2004-066:  Education Affiliation Agreements


  1. RESCISSIONS:  Patient Care Memorandum-11-066-LM December 2012.

Attachment A, B, C

Attachment D

© 2017 by Thomas Fohr