business of Medicine
Onboarding Practice Managers Toolkit
Advanced practice clinicians
Collaborative/protocols for midlevel providers
The expansion of health insurance coverage through healthcare reform along with the aging population is expected to strain the capacity for providing healthcare.1 The number of midlevel providers (MLPs) also known as physician extenders are increasing at a rapid pace. Collaborative agreements/protocols form the framework for the working relationship between providers and midlevel providers.
- Understand state requirements for collaborative agreements, protocols, QA activities, face-to-face meetings, etc. Assure these activities are being documented and are kept well-organized.
- Practice protocols should be clear and to the point. Avoid unnecessary verbiage or detail—in a lawsuit, you will be held accountable for, and limited to, these protocols. The protocols should be reviewed at intervals to assure they are clinically up to date, practical, achievable and make sense for your practice setting and patient population. Lastly, they should be readily accessible, neat and well-organized. Juries make judgments about clinical competence based in part on whether or not defendants in a lawsuit come across as organized and conscientious in other matters. Good protocols encourage good practice and can be invaluable in defense of a lawsuit.
- Too much information: too much information may create an unrealistic standard of care; not enough information may create an appearance of careless supervision;
- Out of Date Content: (Out of date content can significantly impact the defensibility of a lawsuit); sloppy, disorganized material undermines a professional’s credibility.
- Protocols not dated: Date and archive revisions; keep them on file for at least seven years—they may be requested in a lawsuit.
- Incomplete guidelines: Written guidelines should cover exam, treatment, delegation, supervision, how often the physician should see the MLP’s patients, patients’ right to access the doctor and medical record documentation review/co-signatures.
- Inconsistent plans of care: Agree upon a consistent plan for dealing with pain management and narcotic medications and monitor MLP prescription practices. Complications (and subsequent litigation) related to narcotic pain management are increasing rapidly.
- Lack of Informed Consent: If you utilize MLPs to perform procedures, be certain patients and family members understand who will be performing the procedure, and that documentation related to informed consent reflects this understanding.
Physicians may delegate responsibility, but retain liability.
Contact your state medical and nursing boards for sample collaborative agreements, job descriptions and detailed information on how to prepare written protocols.
Medical supervision of mid-level providers
Changes in the health care delivery system, combined with the projected shortage of primary care physicians, will increase the demand for mid-level providers (MLPs). One of the key recommendations from the 2010 Institute of Medicine’s report on the Future of Nursing was to “remove scope of practice barriers.” Further clarified, the advanced practice RN should be able to practice to the full extent of their education and training.”1
Although there are efforts in many states to expand the independence of MLPs, most states continue to require medical supervision. Supervising physicians and employers will almost always be named as additional defendants in a medical malpractice suit involving a MLP. The most common allegations are inadequate supervision and failure to comply with state-specific supervision requirements.
The liability of the supervising physician falls under the respondeat superior doctrine; “let the master answer.” The “master” is liable, in certain cases, for the wrongful acts of his/her “servant.” Physician liability under respondeat superior doctrine for a mistake made by a MLP would depend on whether an employer-employee or a principal-agent relationship exists. Negligent supervision is often alleged when physician supervisors fail to respond, are unavailable, or provide inadequate training. Physicians may delegate responsibility, but they will retain liability.
By giving careful attention to each of these strategies, physicians providing medical supervision may reduce risks associated with MLPs:
- Ensure the MLPs you hire have and maintain proper credentials.
- Carefully delineate the scope of the MLP’s practice and set limits.
- Limit the MLP’s clinical activities to the scope of clinical privileges granted to the supervising physician.
- Mentor the MLP to enhance communication.
- Conduct regular and periodic reviews of the MLP’s activities and clinical responsibilities.
- Encourage the MLP to seek guidance from the supervising physician(s) as needed; encourage questions.
- Require MLPs to wear badge identification to avoid any misunderstanding about their credentials.
- Provide patients with a mechanism to access the supervising physician, if they choose or request.
- Familiarize yourself with state-specific laws related to the scope of practice and supervision requirements for MLPs.
- Do not allow MLPs to perform clinical activities under any physician not authorized/approved to provide them medical supervision.
- Ensure that the MLP is properly trained for your practice setting.
- Review/update job descriptions, policy statements, practice protocols, collaborative and employment agreements on at least an annual basis.
- Keep a copy of the collaborative agreement on file in each practice location.
- Develop and approve guidelines concerning prescriptive practices. At minimum, the guidelines should:
- Identify the supervising/collaborating physician(s);
- Identify the types of medications to be prescribed as well as limitations;
- Define provisions for managing emergencies; and
- Specify the frequency of reviewing prescriptions written for controlled substances.
- Define a process for the ongoing review of care provided for one or more frequently encountered clinical problem(s).
- Plan scheduled meetings with the MLP at least monthly for the first six months and at least quarterly thereafter or as often as otherwise required by state-specific requirements.
- Document any clinical problems discussed and a plan for improvement.
- Be sure that professional liability insurance includes coverage for MLPs.
- Contact your malpractice carrier immediately when adding MLPs.
Although some national groups are calling for more consistency in the regulatory requirements for MLPs, it is important to be aware that state-specific requirements for advanced practice RN’s (APRNs) and physician assistants (PAs) may be different for each state. It is important to familiarize yourself with state-specific requirements for each type of MLP you supervise as these may vary as well.
MagMutual Risk Management and Patient Safety Consultants invite our policyholders’ questions. If you wish to discuss issues related to this article, or have other questions please call us at 1-800-282-4882, and ask for Risk Management.
Some professional organizations associated with MLPs:
Malpractice risks with NPs and PAs in Your Practice. (2013). Medscape Business of Medicine WebMD, LLC.
The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.