Mid-level Practitioners: Shared Benefits, Shared Risks

Susan Shepard, MSN, RN, Director, Patient Safety Education.

Mid-level practitioners (MLPs) are firmly entrenched in today’s healthcare system. Their role has broadened substantially since the first training programs were created in response to a physician shortage approximately 40 years ago. MLPs now perform both routine and complicated medical services for hospitals and medical practices across the country.

According to closed claim data compiled by PIAA for the 10-year period of 2001 through 2010, 28.4 percent of closed professional liability claims involving physician assistants (PAs) and nurse practitioners (NPs) resulted in an indemnity payment. In most cases, the indemnity payment was made on behalf of the MLP by the supervising physician’s policy or that of the practice’s professional association. The most prevalent misadventure (allegation) for both PAs and NPs was “error in diagnosis.”

Data from the Centers for Medicare and Medicaid Services show that in 2010, there were 106,000 practicing NPs and 70,000 practicing PAs in the United States. The number of practicing MLPs continues to grow, with an expected increase of between 7 percent and 10 percent annually over the next several years. With the passage of the Patient Protection and Affordable Care Act, the need for MLPs will be greater than ever. As their skill level and visibility rise, so do opportunities for litigation.

Doctors who work with MLPs must be aware of their respective roles and the liability exposures that may result. Since MLPs can be full partners with the physician in matters of litigation, it is imperative that medical practices design purposeful measures to keep exposures to a minimum. Don’t wait for a claim or lawsuit to begin thinking about these concepts—initiate meaningful changes today that will protect you and your healthcare team into the future.

The patient safety recommendations for physicians who work with MLPs include the following:

  • Prior to employment, get authority to check the MLP’s licensing and certifications. Verify the MLP’s education, background, and other credentials carefully.
  • When scheduling appointments, staff should always inform patients when they are being scheduled with an MLP, and staff should give the patient a choice.
  • MLPs should wear identification that indicates who they are, such as “Sue Smith, NP.”
  • Have a written policy that defines the MLP’s role as clearly as possible, including how your practice will operate using mid-level practitioners. Have the MLP, as well as each staff member, sign the policy annually.
  • Develop categories of patients that should be seen by the physician, as well as treatment guidelines and clinical triggers for physician consultation. Any uncertainty by the MLP about the patient’s clinical status should result in a personal examination by the physician.
  • Crosscheck the job functions of the MLP with state regulatory requirements.
  • Read our online booklet, Mid-level Practitioner Liability—Preventive Action and Loss Reduction Plan, for more information.
  • Respect the limits of the MLP’s scope of practice. Too much delegation can create unnecessary risk.
  • Meet with the MLPs regularly to discuss their roles and expectations within the practice, and document the meetings.
  • Review the charts, including prescription monitoring, of patients seen by the MLPs with some degree of regularity.
  • Make sure that all staff members, including MLPs, have adequate professional liability coverage. For nonemployed MLPs, liability coverage should be equal to what you or your practice carries.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J10152 08/13

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