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Oct 31 2008

Supervision of midlevel practitioners: How much is enough?

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Image for Supervision of midlevel practitioners: How much is enough? On a basic level, we all know what it means to supervise someone. But how much supervision is appropriate when it comes to the physician’s duty to oversee physician assistants or nurse practitioners?

There is no one right answer. The level of supervision expected by the North Carolina Medical Board depends on a range of factors, such as the number of practitioners under a physician’s supervision and whether supervisor and supervisee practice at the same physical location. Each professional relationship will look different, based on the unique circumstances of each case. The bottom line—which all physicians who supervise mid-level practitioners would do well to keep in mind—is that the physician is ultimately responsible for ensuring that high quality medical care is provided to each patient. Physicians also should understand that they may be held accountable if they fail to provide adequate oversight or if PAs or NPs under their supervision make errors or exhibit poor clinical judgment.

This article will review the NC Medical Board’s position on supervision of midlevel practitioners and provide an overview of the corresponding rules and regulations. It also will cover some of the common problems that arise.

First, a little context
It’s never been more critical for supervising physicians to understand their obligation to provide adequate oversight. Midlevel practitioners are an increasingly important part of how we deliver primary care in North Carolina. Between 1996 and 2005, the number of PAs practicing in North Carolina increased by 100 percent, according to an analysis published in 2007 by researchers at the Cecil G. Sheps Center for Health Services Research. The number of NPs in the state increased 220 percent over the same period, according to the same research. As of October, nearly 10 percent of all physicians licensed by the NC Medical Board supervised one or more PAs. Nearly 8 percent supervised one or more NPs.

Some of these midlevel practitioners see patients at locations where there is no physician on-site and little face-to-face interaction with the supervising physician. In recent years, North Carolina and other states have seen rapid growth of “retail” health clinics in drug and discount stores. These clinics, which handle a set menu of common ailments, are typically staffed exclusively by nurse practitioners whose clinical practice is overseen by off-site physicians. The Board has observed that the level of supervision at such clinics varies widely. Even when midlevel practitioners work at the same practice location as their supervisors, it is no guarantee that adequate oversight is in place.

The Board frequently reviews and takes regulatory action in cases in which the level of supervision of PAs and NPs is an issue. Sometimes the cases involve administrative or procedural issues. This category might include such conduct as a PA seeing patients before receiving a confirmation of intent to practice from the NCMB or failure on the physician’s part to meet a midlevel practitioner in person and observe that person’s clinical practice before agreeing to supervise. It’s not uncommon for supervising physicians to be disciplined for keeping insufficient documentation of quality improvement meetings or having no, or inadequate, scope of practice and prescriptive authority documents.

The Board also reviews many cases that involve quality of care provided by midlevel practitioners. In one recent case, a PA failed to properly diagnose abdominal aortic aneurysm in a patient who later died. The case led to a malpractice payment on the behalf of the PA. After reviewing the facts of the case (the Medical Board reviews every new malpractice payment made on behalf of each NC licensee) the NCMB issued Public Letters of Concern to both the PA and the supervising physician, who had signed off on the midlevel practitioner’s diagnosis. Prescribing problems also generate a fair number of cases. For example, a PA or NP might prescribe controlled substances without adequately documenting the need or prescribe to family members. It is fairly typical for the Board to discipline both the midlevel practitioner and the physician in these types of cases, resulting in public records for each practitioner.

So what is appropriate supervision?The NCMB recognizes that determining the right level of supervision is no easy matter. There are numerous possible practice settings and supervisory situations, as well as a spectrum of skill and experience levels among supervised practitioners. Appropriate supervision will be different for each and every situation. However, North Carolina statute and administrative rules set out basic criteria. Following these requirements conscientiously when you establish supervisory relationships is the best defense against future problems.

The rules that pertain to supervision of PAs and NPs are too lengthy and complex to fully cover in this article. Briefly, rules for establishing the supervisory relationships among PAs, NPs and supervising physicians require:
  • That the PA or NP file, respectively, an ‘intent to practice’ or ‘approval to practice’ form with the appropriate regulatory board(s) and obtain confirmation of its receipt and/or approval before performing medical acts, tasks or functions under the supervising physician. PAs must file this form with the NCMB. NPs, who are dually approved by the NC Board of Nursing and the NCMB, must submit the ‘approval to practice’ form to both the NCMB and NCBON.

  • That the PA or NP work with the primary supervising physician to create a written document that outlines in detail the practice arrangement, including scope of practice, duties, responsibilities and terms for prescribing and dispensing of drugs and medical devices. The delegation of medical tasks must be appropriate to the skill level and competence of the PA or NP. This document must be signed by both the supervisee and the supervising physician(s).

  • That a process for evaluation of the supervisee’s performance be established.

  • That the PA or NP receive from the supervising physician written instructions for prescribing, ordering and administering medical devices and a written policy for periodic review by the physician. In order to prescribe controlled substances, the midlevel practitioner must have a valid DEA registration and prescribe in accordance with all applicable policies and guidelines.

  • For PAs in a new practice arrangement, meetings with the primary supervising physician must occur monthly for the first six months to discuss clinical matters and quality improvement (QI). After the first six months, such meetings must take place at least every six months. All meetings must be documented.

  • Generally, the rules for established NPs entering a new practice arrangement mirror those for PAs. New NPs entering their first collaborative practice arrangement must meet more frequently with the supervising physician and meet additional requirements.

  • That midlevel practitioners identify themselves clearly and appropriately. PAs should wear name tags identifying themselves as physician assistants; NPs should wear tags identifying themselves as nurse practitioners.

This is just a summary of the rules. The full texts include important requirements about the level of detail expected in collaborative practice agreements and supervisory arrangements, how often these documents must be reviewed and updated, how meetings should be documented and how long those records must be kept, among other subjects. Supervising physicians, NPs and PAs will want to become intimately acquainted with these requirements. The applicable rules and statutes can be found on the NCMB Web site, Click on the tab marked ‘For Physician Extenders/Perfusionists’ and select Rules and Regulations from the menu at the left of the page.

To further guide its licensees on the subject of physician supervision of midlevel practitioners, the NCMB in 2007 adopted a position statement titled, “Physician Supervision of Other Licensed Health Care Practitioners”. The position emphasizes the Board’s expectation that physicians provide adequate oversight and ensure that quality medical care is provided to patients seen by midlevel practitioners. It also lists several of the factors that help determine the appropriate level of supervision. The full text of the position statement is published below. It also can be found on the Board’s Web site.

Finally, this year the Board established a random audit program to ensure compliance with rules and laws that govern PA supervision. A similar program for NPs has been established in conjunction with the NC Board of Nursing. Half of these audits are conducted by mail, with randomly selected practices completing forms to indicate compliance, and the other half are conducted by field investigators who visit practices in person. The purpose of the audits is to document compliance, which is consistent with excellence in clinical care. Practices are typically given the opportunity to correct any deficiencies in their supervisory arrangements with PAs and NPs. However, some audits may turn up problems that may lead the NCMB to take disciplinary action.

I encourage any physicians who supervise midlevel practitioners—or are contemplating such relationships —to become thoroughly familiar with what is required before Board investigators knock on their doors.
PA documents you must have on site
      Proof of licensure and registration

      Statement of supervisory arrangement with primary supervising physician (Scope of Practice)

      Signed and dated record of meetings between primary supervising MD and PA relevant to clinical problems and QI measures

      List of all back-up supervising physicians, signed and dated by MDs (primary and backups) and PA

      Written prescribing instructions to include written policy for periodic review of these instructions by primary supervising MD

      DEA registration and pharmacy permit, if applicable

NP documents you must have on site
      Proof of RN licensure, registration and approval to practice

      Proof of registration and national certification if applicable

      List of all back-up supervising MDs, signed and dated by primary and back-up MDs and NP

      Collaborative Practice Agreement with documentation and annual protocol review

      CE documentation

      QI process documents to include documentation of NP-MD consultation meeting

      DEA Registration and Pharmacy Permit, if applicable

NCMB Position Statement: Physician Supervision of Other Licensed Health Care PractitionersThe physician who provides medical supervision of other licensed healthcare practitioners is expected to provide adequate oversight. The physician must always maintain the ultimate responsibility to assure that high quality care is provided to every patient. In discharging that responsibility, the physician should exercise the appropriate amount of supervision over a licensed healthcare practitioner which will ensure the maintenance of quality medical care and patient safety in accord with existing state and federal law and the rules and regulations of the North Carolina Medical Board. What constitutes an “appropriate amount of supervision” will depend on a variety of factors. Those factors include, but are not limited to:
  • The number of supervisees under a physician’s supervision

  • The geographical distance between the supervising physician and the supervisee

  • The supervisee’s practice setting

  • The medical specialty of the supervising physician and the supervisee

  • The level of training of the supervisee

  • The experience of the supervisee

  • The frequency, quality, and type of ongoing education of the supervisee

  • The amount of time the supervising physician and the supervisee have worked together

  • The quality of the written collaborative practice agreement, supervisory arrangement, protocol or other written guidelines intended for the guidance of the supervisee

  • The supervisee’s scope of practice consistent with the supervisee 's education, national certification and/or collaborative practice agreement

(Adopted July 2007)
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