Transcript SupervisionNPsandPAsx

Supervision of physician assistants and nurse
practitioners
Marcus Jimison, JD
Senior Board Attorney
North Carolina Medical Board
1203 Front Street | Raleigh, NC 27609
www.ncmedboard.org
| [email protected]
North Carolina
Medical Board
800.253.9653
www.ncmedboard.org | [email protected]
Objectives
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Demographics and supervision overview
Resources and information available to licensees
Board expectations for supervision
NCMB PA site visit (compliance) program
Common areas of concern
Q&A
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Who supervises?
• NCMB currently licenses more than 35,000
physicians (MDs and DOs) and about 5,500
physician assistants
• Approximately 11 percent of licensed
physicians act as primary supervisors for one
or more PAs or nurse practitioners
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Supervision overview
• Supervision shall be continuous, but the physician
does not have to be on site
• Supervisor must be available to supervisee on a
continuous basis (e.g. by telephone is OK)
• Supervising physician is responsible for the care
rendered by supervisee
• Unless specifically ordered by the Board,
supervising physicians are NOT required to sign
off on supervisees’ patient charts
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Supervision overview
• Only physicians with full, active NC medical
licenses who are not prohibited from supervising
can act as primary or back up supervisors
• Physicians with public disciplinary history may be
supervisors; PAs advised to check record before
signing contracts.
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Supervision overview
• No limit on the number of NPs or PAs that may be
supervised by a physician
• However, physician must appropriately supervise
each NP or PA and meet all obligations
• It is challenging for supervising physicians to
adequately supervise large numbers PAs or NPs
• Conversely, it is inadvisable for multiple
physicians to serve as primary supervisors to a
single NP/PA
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Objectives
• Demographics and supervision overview
• Resources and information available to
licensees
• Board expectations for supervision
• NCMB PA site visit (compliance) program
• Common areas of concern
• Q&A
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Supervision resources
• Position Statement - “Physician supervision of
other licensed health care practitioners”
• NCMB administrative rules (21 NCAC 32S)
Both accessible on NCMB website under
Resources & Information – Professional
Resources – Laws, Rules & Position Statements
North Carolina Medical Board
www.ncmedboard.org | [email protected]
North Carolina Medical Board
www.ncmedboard.org | [email protected]
North Carolina Medical Board
www.ncmedboard.org | [email protected]
North Carolina Medical Board
www.ncmedboard.org | [email protected]
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Objectives
• Demographics and supervision overview
• Resources and information available to
licensees
• Board expectations for supervision
• NCMB PA site visit (compliance) program
• Common areas of concern
• Q&A
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Board expectations
• Board’s goal is for NPs and PAs to develop a
true collaborative working relationship with
their supervisors
• Supervisors should understand that
supervision in name only is not acceptable
• Proper documentation and retention of
supervision documents is expected
• Follow the rules – 21 NCAC 32S
North Carolina Medical Board
www.ncmedboard.org | [email protected]
New supervisees
• Primary supervising physician must meet monthly
with new supervisee for the first six months
• Meetings should cover practice relevant clinical
problems and quality improvement measures.
• After first six months, regular meetings should be
held no less than every six months (2X a year)
• A record of QI meetings should be signed/dated
by both the supervising physician and the PA
North Carolina Medical Board
www.ncmedboard.org | [email protected]
What is appropriate supervision?
NCMB Position Statement specifies factors that
determine the necessary level of supervision, including:
o Supervisee’s level of training, years of experience
and practice setting
o Length of time supervisee and supervisor have
worked together
o Geographic distance between supervisor and
supervisee
o Number of supervisees working under supervisor
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Elements of appropriate supervision
• Supervisee’s scope of practice is clearly defined,
in writing
• Relationship to/access to each supervisor is
defined. NPs and PAs can reach supervisors
within a reasonable amount of time
• There are written instructions for prescribing,
ordering and administering drugs, and a written
policy for periodic review of the instructions.
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Elements of appropriate supervision
Physicians and supervisees must ensure:
• Scope of practice is sufficiently detailed; Should
include specific medical tasks or functions,
including prescribing and dispensing of drugs and
medical devices, that may be performed by the
PA/NP
• Medical tasks must be appropriate to the skills
and competencies of both the PA/NP and the
supervising physician.
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Real life example
• Board receives information that MD is supervising an
NP trained to read musculoskeletal ultrasounds; MD
is not trained to interpret these studies
• Independent expert finds use of musculoskeletal
ultrasounds “unacceptable and unreasonable”
Board action: MD suspended for 12 months, stayed.
MD fined $5,000, prohibited from supervising midlevels
who order/interpret musculoskeletal ultrasounds. MD
required to meet monthly with all supervisees for 12
months; NP suspended 12 months, stayed
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Elements of appropriate supervision
Per NC administrative rules, the supervisor and
supervisee must ensure that:
• Delegation of medical tasks is appropriate to the
skills of the supervising physician and the PA’s level
of competence.
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Real life example
• PA practicing with no on site supervision administered
insulin injections to a patient with new onset Type II
diabetes; PA demonstrated a poor understanding of
the pathophysiology of diabetes and the
pharmacology of insulin
• PA administered three doses of 40 units each of SQ
regular insulin within approximately 30 minutes;
patient became lightheaded and collapsed; taken to
local ER
• At no time did PA contact supervising physician
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Real life example, cont’d
• PA prescribed increasing levels of analgesics and
benzodiazepines to a patient with anxiety and pain
• When contacted by phone and told that patient was
experiencing “mental changes”, patient advised to
take more Valium; PA did not consult with supervisor
• PA failed to appropriately instruct patient on how to
take medications, resulting in the patient suffering
delirium and presenting to local ER
• Investigation revealed two other examples of
substandard care
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Real life example, cont’d
Board action: PA suspended for 12 months, stayed.
PA required to:
• Practice only in settings with on site supervision;
• Implement a plan of remediation to address
knowledge gaps; also ordered to CPEP for evaluation
• Meet weekly with primary supervisor and have
charts co-signed by supervisor
• Primary supervising physician disciplined: Reprimand
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Objectives
• Demographics and supervision overview
• Resources and information available to
licensees
• Board expectations for supervision
• NCMB PA site visit (compliance) program
• Common areas of concern
• Q&A
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Verifying PA compliance
• NCMB conducts site visits to verify compliance
with supervision rules
• PAs randomly selected for compliance checks
each year
• PAs are notified in advance
• Board investigator visits practice site to review
required documents, verify compliance
• NCBON does compliance checks for NPs
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Results of site visits
• Most supervisor/supervisee teams are found to
be in full compliance with rules
• Approximately 10 percent of compliance checks
uncover a violation serious enough to warrant
public or private discipline
• 25 percent of site visits reveal minor violations
that PAs corrected upon notification by the Board
(no list of backup supervisors at each practice
site, supervisory agreement not signed, dated)
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Problems found
• PA began practice without ITP in place
• No documentation of QI meetings, no backup
supervisors list at practice site
• Issues with supervisory agreement: not sufficiently
detailed, not aligned with actual clinical duties, not
signed and dated by both supervisor and PA, etc.
• PAs prescription blanks did not have his/her
name/telephone, license number, DEA number, and
supervising physician’s name/telephone as required
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Reaching compliance
• NCMB provides a copy of the PA site visit
checklist on its website
• Checklist covers all items expected to be
produced for Board examination at each
practice site
• PAs provided advance notice of site visit –
ample opportunity to review documents and
achieve compliance prior to visit
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Finding the site visit checklist
• Fastest way to form is site search (top right
corner of NCMB website)
• Click on the magnifying glass and search using
PA Forms
• PA Forms page includes links to ITP, backup
supervisor form and the Site Visit checklist
• Download the form and use as a guide to
ensure all required materials are in place
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Site search
ITP
Objectives
• Demographics and supervision overview
• Resources and information available to
licensees
• Board expectations for supervision
• NCMB PA site visit (compliance) program
• Common areas of concern
• Q&A
North Carolina Medical Board
www.ncmedboard.org | [email protected]
No ITP before seeing patients
• A completed Intent to Practice (ITP) form must
be received and accepted by the Board before
a PA can begin performing medical tasks
• ITP notifies NCMB of supervising physician (s)
• Practicing without ITP can be grounds for
disciplinary action
• New ITP MUST be completed for each new
primary supervisor
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Additional notes on ITP
• ITP also used to REMOVE a primary supervisor
• It is the responsibility of the PA or NP to
remove the old supervisor (usually when
he/she adds a new primary)
• NPs add/remove supervisors through NCBON
• If NP or PA fails to remove the physician, the
NP or PA will continue to display as an active
supervisee of that physician
North Carolina Medical Board
www.ncmedboard.org | [email protected]
How do I know that ITP was received?
• PAs may look the supervising physician up at
www.ncmedboard.org using the Look up a
doctor or PA tool
• If their name is listed as a supervisee, the ITP
has been processed by the Board
• Confirmation of ITP letters are no longer
mailed; confirmation emails are sent to
supervisor and to PA (save this email)
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Too many primary supervisors
• NCMB has observed an increasing number of
PAs designating several physicians as
“primary” supervisors
• If everyone is supervising is anyone
supervising?
• NCMB believes supervision works best when
one physician takes responsibility for working
with the PA or NP
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Too many supervisees/little contact
• An appropriate supervisory relationship
involves true collaboration between the
supervisor and supervisee
• Regular meetings to discuss QI is expected; at
least some of these meetings should occur
face-to-face; personalized to individual
supervisee’s needs/concerns
• MD/DO cannot be supervisor in name only
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Real life example
• MD employed by a retail medical clinic chain
supervises about 20 midlevels
• NCMB investigation reveals that MD failed to
document that required QI meetings were
conducted for all supervisees
• Documented QI meetings often conducted in
large groups (12+ midlevels)
• Board Action: Public letter of concern issued to
MD; MD advised of obligations stated in rules
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Delegation to unlicensed personnel
• NCMB fields many questions about what
medical tasks may be delegated to unlicensed
personnel working in a medical practice
• Law permits a physician to delegate “acts,
tasks, and functions that are … permitted by
law or established by custom.”
• Article on NCMB website includes table of
commonly delegated tasks
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Objectives
• Demographics and supervision overview
• Resources and information available to
licensees
• Board expectations for supervision
• NCMB PA site visit (compliance) program
• Common areas of concern
• Q&A
North Carolina Medical Board
www.ncmedboard.org | [email protected]
Thank you
Additional questions?
Marcus Jimison
Senior Board Attorney, NCMB
[email protected]
North Carolina Medical Board
www.ncmedboard.org | [email protected]