===== Supervision Level =====

**Supervision level** refers to the degree of direct oversight provided to a surgeon—typically a resident or junior attending—during a procedure. It is a critical factor when interpreting CUSUM results and setting appropriate thresholds or reference values.

==== Categories of Supervision ====

  * **Direct supervision**: A senior surgeon is physically present and guiding the procedure step-by-step.
  * **Indirect supervision**: A supervisor is available on-site but not scrubbed in; the procedure is performed independently.
  * **Unsupervised (autonomous)**: The operator performs the procedure independently, without on-site backup.

==== Impact on CUSUM Interpretation ====

  * With **direct supervision**, the expected complication rate (''k'') should be **lower**, and the alert threshold **stricter**, since expert guidance minimizes error.
  * With **indirect or no supervision**, a slightly higher ''k'' or more forgiving threshold may be appropriate to account for operator learning or complexity.

Example:
  * For ICP monitor placement under direct supervision → ''k = 0.08'', threshold = 2.0
  * For independent placements by senior residents → ''k = 0.12'', threshold = 2.5

==== Educational and Clinical Use ====

CUSUM charts stratified by supervision level allow:
  * **Tailored feedback** to individual trainees
  * Identification of readiness for **progressive autonomy**
  * Adjustment of supervision strategies based on **real-time performance**
  * Objective support for credentialing and privileging decisions

By incorporating supervision level into CUSUM analysis, training programs can make more **nuanced, fair, and accurate** judgments about performance and progression.