Supervision and Oversight of Advanced Practice Providers

Supervision and Oversight of Advanced Practice Providers Foreseeing the Risks and Considering Ways to Reduce Liability   Laura M. Cascella, MA Docto...
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Supervision and Oversight of Advanced Practice Providers Foreseeing the Risks and Considering Ways to Reduce Liability   Laura M. Cascella, MA Doctors and advanced practice providers (APPs) who work together often share responsibility for patient care, as well as liability risks. Yet, doctors who assume supervisory roles of APPs have additional responsibilities. They must ensure that they are delegating appropriate tasks, offering adequate consultation, and providing appropriate oversight of APP practice. The American Academy of Family Physicians states that doctors are responsible for ensuring that all delegated tasks fall within the APP’s scope of practice, that APP care is consistent with accepted medical standards, and that directions — whether written or verbal — are given appropriately, understood, and followed. 1 The Academy of General Dentistry (AGD) also takes a strong stance on the doctor’s responsibility for oversight. In its Position on Workforce Issues, AGD states that it believes in providing direct supervision for allied dental personnel within the dental team, and “placing the responsibility squarely on the shoulders of dentists . . . for safeguarding the health and safety of patients.” 2 Despite what may seem like a fairly straightforward charge, supervision is a multifaceted and complex role. It involves understanding and adhering to regulations and standards that are defined at many level and by various factors. Failure to comply with the required regulations and standards may result in allegations of negligence for both the APP and supervising doctor.

The Doctor’s Perspective

Graham Billingham, MD, FACEP, FAAEM As healthcare changes, roles for certain APPs may expand, causing changes — and therefore increased risk — in the supervision of APPs. States may have clear regulations regarding the scope of practice, documentation requirements, appropriate levels of supervision, and staffing ratios. In some states, certain APPs may work independently, while in other states, they are expected to work closely with their physician and dentist colleagues. State regulations also may mandate differing degrees of supervision for varying types of APPs. As regulatory efforts increase, medical and dental practices’ policies and protocols related to APP practice should reflect changes in supervision requirements to reduce risk. Inadequate supervision can result in diagnostic errors, delayed treatment, poor communication, and other allegations of negligence. Further, adequate supervision goes beyond merely complying with regulations; it must focus on creating a collaborative practice in which both APPs and doctors are comfortable. The goal should be to create a practice environment that emphasizes excellence in communication between all providers. Putting procedures in place that address the issue of supervision in a collaborative fashion is more important than ever because of the growing demand for healthcare providers. Establishing an appropriate level of supervision for APPs in a collaborative and supportive environment will contribute to a successful program — one that both improves outcomes and decreases risk.

Dr. Billingham is MedPro Group’s Chief Medical Officer. He has more than 25 years of experience as an emergency medicine physician, has served on the American College of Emergency Physicians’ Medical Legal Committee and Coding and Nomenclature Committee, and is Emeritus Chair of the Emergency Medicine Patient Safety Foundation.

How Supervision Contributes to Malpractice Claims The impact of inadequate supervision is reflected in malpractice trends for APPs. According to a 2013 American Medical News article, “Failure-to-supervise claims are among the most common legal allegations stemming from failed team care . . . .” 3 MedPro Group data show that diagnosis-related and medical treatment allegations make up the majority of claims volume for APPs. 4 A more in-depth analysis indicates that many of the factors that contribute to the top allegation categories are either directly related or strongly correlated to supervision and oversight.

APP Allegation Categories and Contributing Factors, MedPro Claims Analysis, 2001–2011*

Allegation Categories

Contributing Factors†

* Charts contain data for physician assistants, nurse practitioners, and certified registered nurse anesthetists. Data for other medical APPs and dental therapists are not available for the timeframe indicated. †

Included in the contributing factors are patient assessment issues/narrow diagnostic focus, delay in ordering consult, lack of supervision, provider-to-provider communication failures, inconsistent documentation (between APP and doctor), and failure to follow policies/procedures.

Consider the following cases, which illustrate the negative consequences and outcomes that can occur when doctors do not provide adequate and appropriate supervision of the healthcare professionals they oversee. •

Case 1: An APP in a hospital-based family practice saw a patient who had a dry cough and was eventually diagnosed with pneumonia. Despite documenting symptoms consistent with pleural effusion, the APP did not order a chest X-ray. Because the doctors in the practice were not familiar with the hospital’s supervision policies and procedures, no one reviewed the APP’s charts. Over the next several months, the patient complained of increasing dependence on an inhaler, gastrointestinal issues, and pain in the upper chest and back when swallowing. In response, the APP ordered an abdominal ultrasound and lab work. Although the results of both suggested the need for further analysis, the APP told the patient that all of the test results were normal. With no oversight, these mistakes slipped through the cracks. Several months later, a physician who was evaluating the patient for recurrent pneumonia ordered a chest X-ray, which led to a diagnosis of stage IV lung cancer. The patient filed a lawsuit against the APP, two family practice physicians, the hospital, and the healthcare system.



Case 2: An APP who was employed by a psychiatrist began a personal relationship with one of the patients he counseled. After the relationship ended, the patient filed a complaint with the state’s board of medicine and brought a malpractice suit against the psychiatrist that alleged negligent supervision and vicarious liability for the APP’s actions. The state where the case took place had regulations stipulating that the doctor and APP had to meet at least monthly for the first 6 months of employment and every 6 months thereafter to review the APP’s cases and discuss patient management issues. The state required that these meetings be documented. Although the doctor claimed that she had adhered to the state’s regulations for supervision and oversight, she had no written documentation to corroborate her claim. Further, she and the PA had never established a written policy for consultation or chart review.

Although these cases deal with two entirely different types of risks, both highlight how deficiencies in supervision can compromise patient safety and expose both the doctor and the APP to liability risks. Both cases also stress the need for careful consideration of supervision policies and procedures within healthcare practices.

Supervision Considerations A number of legal, regulatory, and organizational considerations will likely play a role in determining requirements and best practices for supervision at your practice. The questionnaire below is intended to help focus those considerations, and potentially identify (a) gaps in policies or protocols related to supervision, or (b) areas that could benefit from further clarification. Yes

1.

Are you aware of your state’s regulatory requirements for supervision of APPs?

2.

Does your state’s regulations related to supervision specify: a. The maximum number of APPs a doctor can supervise? b. The required geographic proximity between doctor and APP (if offsite supervision is allowed)? c. The acceptable methods of oversight (in person, electronic, via phone)? d. Thresholds for review of charts (including signature) and timeframes for review? e. Whether a collaborative agreement and/or written

protocols related to supervision are required?

3.

Does your practice monitor for changes in state regulations related to supervision?

4.

Does your practice have written guidelines that (a) outline situations that require oversight/supervision, and (b) define specific triggers for consultation with or referral to the doctor?

5.

Are guidelines periodically reviewed and updated to ensure the content is current and relevant?

6.

Do supervising doctors in the practice ensure that delegated tasks are within each APP’s appropriate scope of practice?

7.

Do supervising doctors in the practice consistently and routinely validate APPs’ competency and clinical skills through review of charts, referrals, documentation, clinical decision-making, and compliance with guidelines and standards of care?

8.

Does your practice have specific standards and thresholds for chart review beyond those that are required by state law?

No

Yes

9.

No

Are all supervisory meetings and consultations between doctors and APPs documented?

10. Are APPs monitored for compliance with billing standards and other corporate procedures? 11. Is a plan in place that specifies how APPs should handle patients requiring emergency care or urgent care that is outside their scope of practice? (NOTE: This is particularly important if the APP and supervising doctor are not always at the same location.) 12. Does the practice have contingency plans for supervising APPs in the absence of the designated supervisor (e.g., during vacation, sick leave, etc.) 13. Do supervising doctors in your practice conduct routine performance evaluations for APPs? Do evaluations offer constructive criticism and opportunities for growth and development? 14. Do APPs participate in your practice’s performance improvement initiatives, including periodic reviews of health records and treatment plans? 15. Does your organization have a process for collecting practice data specific to APP activities for inclusion in performance improvement initiatives?

Conclusion Supervision and oversight of APPs presents unique challenges in the practice setting. Physicians and dentists who supervise APPs have a duty to ensure that they are delegating appropriate tasks, providing adequate consultation and support, establishing alternative provisions for supervision (when needed), and monitoring quality of care. Because doctors can typically be held vicariously liable for the negligent actions of APPs under their supervision, they must be vigilant in establishing and following well-defined policies for oversight. These policies should comply with any specific standards or thresholds set forth in state statutes and regulations, as well as organizational policies.

Endnotes 1

American Academy of Family Physicians. (1992, updated 2013). Guidelines on the supervision of certified nurse midwives, nurse practitioners, and physician assistants. Retrieved from http://www.aafp.org/about/policies/ all/guidelines-nurses.html 2

Academy of General Dentistry. (2010). The Academy of General Dentistry position on workforce issues. Retrieved from http://www.flagd.org/agdworkforceposition.pdf

3

Gallegos, A. (2013, July 29). Physician liability: Your team, your legal risk. American Medical News. Retrieved from http://www.amednews.com/article/20130729/profession/130729942/4/

4

MedPro Group Closed Claims Analysis, 2001–2011.

The information provided in this document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the regulations applicable in your jurisdiction may be different, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal statutes, contract interpretation, or legal questions. The Medical Protective Company and Princeton Insurance Company patient safety and risk consultants provide risk management services on behalf of MedPro Group members, including The Medical Protective Company, Princeton Insurance Company, and MedPro RRG Risk Retention Group. © MedPro Group.® All Rights Reserved.

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