See also:
Nurse Midwives, Certified
Integrated Practice Arrangements
Nurse Practitioners
Physician Assistants
Non-Physician Providers, Family Physician Training With
Payment, Non-Physician Providers
Guidelines on the Supervision of Certified Nurse Midwives, Nurse Practitioners and Physician Assistants
Introduction
Family physicians have utilized certified nurse midwives, nurse practitioners, and physician assistants in extending the availability of health care more than any other medical specialty. Approximately thirty percent of family physicians report utilizing at least one of these non-physician providers (NPPs) in their practices. Moreover, family physicians have been at the forefront of innovation in the utilization of 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 are utilized 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 their supervising physicians. Current Academy policy on NPPs stipulates that these providers always function under the "direction and responsible supervision of a practicing, licensed physician. The Academy, however, believes that practicing physicians and health policy makers will benefit from a more detailed set of guidelines on the supervision of NPPs.
These guidelines are intended to serve as a set of general principles with which physicians and policy makers can assess the role of NPPs 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. 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 plans and physician practices which utilize non-physician care 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.
Family physicians have utilized certified nurse midwives, nurse practitioners, and physician assistants in extending the availability of health care more than any other medical specialty. Approximately thirty percent of family physicians report utilizing at least one of these non-physician providers (NPPs) in their practices. Moreover, family physicians have been at the forefront of innovation in the utilization of 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 are utilized 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 their supervising physicians. Current Academy policy on NPPs stipulates that these providers always function under the "direction and responsible supervision of a practicing, licensed physician. The Academy, however, believes that practicing physicians and health policy makers will benefit from a more detailed set of guidelines on the supervision of NPPs.
These guidelines are intended to serve as a set of general principles with which physicians and policy makers can assess the role of NPPs 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. 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 plans and physician practices which utilize non-physician care 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. Physician supervision means that the NPP only performs medical acts and procedures that have been specifically authorized and directed by the supervising physician.
It is useful to conceptualize state NPP 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 requirements for supervision. The supervising physician bears both the authority and the responsibility for the delegated acts. 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. It is the Academy's position that those services that are delegated to and provided by NPPs are traditional physician services that must be provided with equal quality. To provide services that are substandard quality would establish a second-class system of health care.
The central principle underlying physician supervision of NPPs is that the physician retains ultimate responsibility of the patient care rendered. Physician supervision means that the NPP only performs medical acts and procedures that have been specifically authorized and directed by the supervising physician.
It is useful to conceptualize state NPP 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 requirements for supervision. The supervising physician bears both the authority and the responsibility for the delegated acts. 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. It is the Academy's position that those services that are delegated to and provided by NPPs are traditional physician services that must be provided with equal quality. To provide services that are substandard quality would establish a second-class system of health care.
Supervision Defined
Supervision means to coordinate, direct, and inspect on an ongoing basis the accomplishments of another, or to oversee, with the power to direct, the implementation of one's own or another's intentions. The supervising physician must have the opportunity and the ability to exercise oversight, control, and direction of the services of a NPP. Accordingly, 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.
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 active overview of NPP activities including direct observation of the NPP's ability to take a history and perform a physical examination; (3) 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; (4) regular chart review; (5) the delineation of a plan for emergencies; and (6) the designation of an alternate physician in the absence of the supervisor. The circumstance of each practice determines the exact means by which responsible supervision is accomplished.
Supervision means to coordinate, direct, and inspect on an ongoing basis the accomplishments of another, or to oversee, with the power to direct, the implementation of one's own or another's intentions. The supervising physician must have the opportunity and the ability to exercise oversight, control, and direction of the services of a NPP. Accordingly, 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.
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 active overview of NPP activities including direct observation of the NPP's ability to take a history and perform a physical examination; (3) 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; (4) regular chart review; (5) the delineation of a plan for emergencies; and (6) the designation of an alternate physician in the absence of the supervisor. 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. The physician must provide direction to NPPs in order to specify what medical services should be provided for all types of cases that the NPP is expected to see. 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. From these guidelines, the NPP may provide medical care as an extension of the supervising physician. 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 development of adequate protocols, whether written or oral, requires an initial period during which the NPP works under the close supervision of the physician. The degree of supervision should lessen only when the physician can ensure that the NPP will provide care in accordance with directions and accepted medical standards. Furthermore, 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. The goal is to err on the side of the NPP seeking physician involvement more often than proves to be necessary.
It is the responsibility of the physician to ensure that appropriate directions are given, understood, and executed. The physician must provide direction to NPPs in order to specify what medical services should be provided for all types of cases that the NPP is expected to see. 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. From these guidelines, the NPP may provide medical care as an extension of the supervising physician. 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 development of adequate protocols, whether written or oral, requires an initial period during which the NPP works under the close supervision of the physician. The degree of supervision should lessen only when the physician can ensure that the NPP will provide care in accordance with directions and accepted medical standards. Furthermore, 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. The goal is to err on the side of the NPP seeking physician involvement more often than proves to be necessary.
Review
Supervision is intended to ensure that directions are implemented properly. 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. Generally, state laws limit the number of NPPs that a physician may supervise. The plan for supervision should consider: (1) the training and experience of both the supervising physician and NPP; (2) the duties the NPP will or will not perform without first receiving the physician's guidance and permission; (3) the duties of the NPP is not expected to perform except in emergency; (4) communication arrangements in various situations or practice settings; and (5) the availability of back-up supervisors.
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, and to protect patient welfare. 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.
An NPP should not provide health care services during periods of time when the supervising physician is unavailable unless an alternate supervisor has been designated. Explicit alternate supervising physician requirements are usually set forth in state law.
Supervision is intended to ensure that directions are implemented properly. 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. Generally, state laws limit the number of NPPs that a physician may supervise. The plan for supervision should consider: (1) the training and experience of both the supervising physician and NPP; (2) the duties the NPP will or will not perform without first receiving the physician's guidance and permission; (3) the duties of the NPP is not expected to perform except in emergency; (4) communication arrangements in various situations or practice settings; and (5) the availability of back-up supervisors.
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, and to protect patient welfare. 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.
An NPP should not provide health care services during periods of time when the supervising physician is unavailable unless an alternate supervisor has been designated. Explicit alternate supervising physician requirements are usually set forth in state law.
Remote Supervision
In principle, supervision should recognize the diversity of practice settings in which NPPs are utilized. As a practical matter, the efficient utilization of a NPP, especially in rural areas, will from time-to-time result in off-site physician supervision. It is generally presumed that the supervising physician will routinely be present at the location where the NPP practices. However, few states require the supervising physician to be physically present at all times when a NPP is providing care or the supervising physician to be specifically consulted before a delegated task is performed. Several states make explicit provision for NPP practice at sites remote from the supervising physician's primary office, and the federal Medicare statute provides for remote NPP practice in rural health clinics.
Where on-site supervision is not provided, the burden is on the physician and the NPP to establish that lack of on-site supervision is reasonable under the circumstances. Some states require explicit approval to utilize a NPP in a remote site. If the NPP is providing services at a remote site, the physician and NPP must ensure that distance does not become an impediment to the regular and adequate review of the NPP's work. No decrement in oversight or quality should result from remote supervision.
Generally, the utilization of a NPP at a remote site involves a physician-NPP team that has had sufficient opportunity to establish a close working relationship before the NPP is deployed to the remote site. The supervising physician 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 remote supervision includes an overview of NPP's activities to determine that directions are being followed; immediate availability for necessary consultations; personal and regular review of patient records; and periodic discussion of conditions, protocols, procedures, and patients. (1992) (2002)
In principle, supervision should recognize the diversity of practice settings in which NPPs are utilized. As a practical matter, the efficient utilization of a NPP, especially in rural areas, will from time-to-time result in off-site physician supervision. It is generally presumed that the supervising physician will routinely be present at the location where the NPP practices. However, few states require the supervising physician to be physically present at all times when a NPP is providing care or the supervising physician to be specifically consulted before a delegated task is performed. Several states make explicit provision for NPP practice at sites remote from the supervising physician's primary office, and the federal Medicare statute provides for remote NPP practice in rural health clinics.
Where on-site supervision is not provided, the burden is on the physician and the NPP to establish that lack of on-site supervision is reasonable under the circumstances. Some states require explicit approval to utilize a NPP in a remote site. If the NPP is providing services at a remote site, the physician and NPP must ensure that distance does not become an impediment to the regular and adequate review of the NPP's work. No decrement in oversight or quality should result from remote supervision.
Generally, the utilization of a NPP at a remote site involves a physician-NPP team that has had sufficient opportunity to establish a close working relationship before the NPP is deployed to the remote site. The supervising physician 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 remote supervision includes an overview of NPP's activities to determine that directions are being followed; immediate availability for necessary consultations; personal and regular review of patient records; and periodic discussion of conditions, protocols, procedures, and patients. (1992) (2002)
