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Background: The process of entrustment-placing trust in a trainee to independently execute a task-has been proposed as a complementary metric to assess competence. However, entrustment decision-making by trainee supervisors is not well understood in surgical training. We aim to explore processes underlying entrustment decision-making (EDM) by general surgery program directors., Materials and Methods: Purposive sampling was used to recruit 20 program directors from Accreditation Council for Graduate Medical Education-accredited general surgery training programs to participate in a one-hour semistructured interview. We analyzed interviews using an iterative and inductive approach to identify novel themes associated with the process of trainee entrustment., Results: Qualitative analysis identified that program directors rely on a network of faculty to make entrustment decisions regarding trainees. Perceived trainee competence to perform independent clinical tasks varies significantly in and out of the operating room (OR), with a strong emphasis on entrustment for technical competencies to the exclusion of cognitive competencies. In the OR, entrustment is informed by an attending's reflexive trust and physical presence, trainee labels, and presumed discernment. Outside of the OR, trainee labels, presumed discernment, and transference of competence were identified as critical themes., Conclusions: Modifiable components of entrustment are equally dependent on trainee and faculty behavior. Entrustment is more heavily informed by trainee performance in the OR, despite program directors uniformly stating that judgment outside of the OR is the most critical component of resident training. The inclusion of EDM to evaluate trainee progression should be considered as an important adjunct to established Accreditation Council for Graduate Medical Education milestones., (Copyright © 2019 Elsevier Inc. All rights reserved.)