Guidelines on the Supervision of Certified Nurse Midwives, Nurse Practitioners and Physician Assistants

Introduction

Many family physician practices include non-physician providers (NPPs) such as physician assistants, nurse practitioners and less commonly nurse midwives. Moreover, family physicians have been at the forefront of innovation in practicing with NPPs, especially in underserved communities. The Academy has supported a wide variety of efforts by policy makers to improve access to health care services in underserved communities including the innovative utilization of NPPs.

The increasing variety of situations in which NPPs practice, the emphasis on practice teams, and the growing tendency of health policy makers to identify NPPs as a means of improving the availability of health care services raises important issues regarding the appropriate relationship between NPPs and physicians. Current Academy policy on NPPs stipulates that these providers should always function under the "direction and responsible supervision" of a practicing, licensed physician though in many states nurse practitioners have independent practice authority. Academy policy on "Integrated Practice Arrangements" supports practice teams including NPPs. The Academy, however, believes that practicing physicians, NPPs and health policy makers will benefit from a more detailed set of supervision guidelines.

These guidelines are intended to serve as a set of general principles with which physicians, NPPs and policy makers can assess the role of NPPs in providing patients a team-based medical home and in improving access to health care services.

It is important to note that an extremely varied set of laws and regulations defining the legal relationship between physicians and NPPs has been adopted by the federal government and all 50 states. It’s also important to note that there are major differences in state scope of practice statutes among nurse practitioners, nurse midwives and physician assistants. While these guidelines will provide general direction, physicians and NPPs are urged to fully comply with all federal, state and local laws and regulations regarding health care delivery. Health insurance plans and physician practices which include non-physician providers should provide information to members/patients regarding the possibility of being seen by a non-physician provider. Such information should be stated in clear terms in plan/practice advertisements and communications, the information should be made known to the patient at the time their appointment is made, and should be clearly stated by the non-physician provider at the time the patient is seen.

Physician Responsibility

The central principle underlying physician supervision of NPPs is that the physician retains ultimate responsibility of the patient care rendered when so required by state law. In these cases, physician supervision means that the NPP only performs medical acts and procedures that have been specifically authorized by the supervising physician.

Generally speaking, it is useful to conceptualize state NPP supervision laws as providing physicians with the authority to delegate the performance of certain medical acts to NPPs who meet specified criteria and who function under certain legal requirements for supervision. Accordingly, the tasks delegated to the NPP should be within the scope of practice of the supervising physician. The physician remains responsible for assuring that all delegated activities are within the scope of the NPP's training and experience. The physician must afford supervision adequate to ensure that the NPP provides care in accordance with accepted medical standards

Supervision

It is the responsibility of the supervising physician to direct and review the work, records, and practice of the NPP on a continuous basis to ensure that appropriate directions are given and understood and that appropriate treatment is rendered consistent with applicable state law. Supervision includes, but is not limited to: (1) the continuous availability of direct communication either in person or by electronic communications between the NPP and supervising physician; (2) the personal review of the NPP's practice at regular intervals including an assessment of referrals made or consultations requested by the NPP with other health professionals; (3) regular chart review; (4) the delineation of a plan for emergencies; (5) the designation of an alternate physician in the absence of the supervisor; and (6) review plan for narcotic/controlled substance prescribing and formulary compliance. The circumstance of each practice determines the exact means by which responsible supervision is accomplished.

Direction

It is the responsibility of the physician to ensure that appropriate directions are given, understood, and executed. These directions may take the form of written protocols, in person, over the phone, or by some other means of electronic communication.

Protocols developed by the supervising physician and NPP should include guidelines describing and delineating NPP functions and responsibilities. Protocols should be as specific in their guidance as the physician and NPP require for their particular practice. Many states require that the physician and NPP develop detailed written protocols, and, in some instances, these protocols must be submitted to and approved by the state medical board. As a practical matter, it is not possible to cover all clinical situations in written protocols. Nonetheless, there must be a clear understanding between the physician and NPP regarding the actions that may be undertaken by the NPP in all commonly encountered clinical situations and, especially, under what circumstances physician consultation is to be immediately obtained. The physician and NPP must regularly review protocols to ensure their currency in regard to the physician's scope of practice, the range of tasks that have been delegated by the physician and the evolving standards of medical practice. Immediate physician consultation will be indicated for specified clinical situations and in situations falling outside those specified in written and oral protocols.

Review

The supervising physician must develop and carry out a plan to ensure NPP quality of care. This plan must be in compliance with all applicable laws and regulations. The supervising physician must regularly review the quality of medical services rendered by the NPP by reviewing medical records to ensure compliance with directions and standard of care. The minimum frequency with which such review takes place is, in some instances, specified in federal and state law. In establishing the frequency and extent of record review, the physician may consider the scope of duties that have been delegated to the experience of, and the patient load of the NPP.

Off-site Supervision

In principle, supervision should recognize the diversity of practice settings in which NPPs practice. As a practical matter, the efficient utilization of a NPP will at times involve off-site physician supervision. Generally, off-site supervision of a NPP involves a physician-NPP team that has previously established a working relationship. The supervising physician or a designated alternate physician of the same specialty must be available in person or by electronic communication at all times when the NPP is caring for patients. There should be established clear transportation and backup procedures for the immediate care of patients needing emergency care and care beyond NPP's scope of practice. As with on-site supervision, the appropriate degree of off-site supervision includes an overview of NPP's activities including a regular review of patient records; and periodic discussion of conditions, protocols, procedures, and patients. (1992) (2013 COD)