Risk Strategies: Healthcare providers can develop risk strategies by analyzing litigation involving APPs. Litigation frequently targets the APP as well as the supervising physician. Even when an APP may be directly responsible for an action that allegedly caused harm to a patient, claimants often seek to hold the supervising physician accountable. According to a 2010 article in The Physician’s Digest, common allegations against both parties can be broken down into separate categories:

• Failure to adequately supervise the APP.
• Failure to have in place a collaborative agreement.
• Failure to follow the requirements of the collaborative agreement.
• Allowing the APP to practice beyond the scope of his or her collaborative agreement.
• Negligent hiring of the APP.

Allegations occur when APPs fail to:

• Diagnose, or contribute to a delay in diagnosis
• Make a timely referral
• Communicate with the supervising physician
• Practice within the scope of authority

Through better understanding of the nature of the above claims and allegations, physicians can develop risk strategies that may help them decrease liability as well as improve outcomes. Effective risk-reduction strategies address hiring practices, orientation, scope of practice, supervision, collaborative agreements, communication, monitoring, and auditing. Strategies for providing appropriate supervision include:

• Providing a clear definition of the location and scope of practice
• Adhering to treatment guidelines
• Holding periodic collaborative meetings to review charts and discuss cases
• Including APPs in the QI process
• Creating an environment in which APPs feel empowered to ask questions
• Incorporating policies and procedures to ensure that office staff, consultants, and patients understand their roles and responsibilities

In summary, adequate supervision goes beyond merely complying with regulations and must focus on creating a collaborative practice in which both the APPs and the physicians are comfortable. It is more important than ever to put procedures in place that address the issue of supervision in a collaborative fashion. It is the appropriate level of supervision for APPs that contributes to a successful program, one that both improves outcomes and decreases risk.

ACEP’s Medical Legal Committee sponsors these articles on medical-legal topics of interest and welcomes input. If you have legal questions that may be informative for others, contact Louise B. Andrew, MD, JD at acep@mdmentor.com. Don’t disclose any details of a pending legal case. For advice regarding litigation stress, contact Marilyn Bromley, 800-798-1822, ext. 3231.

Dr. Billingham is an emergency physician and Chief Medical Officer for Medical Protective Insurance Company and is Emeritus Chair of the Emergency Medicine Patient Safety Foundation. Mr. Callard is a physician assistant at St. Joseph Mercy Hospital, Ann Arbor, Michigan and serves on the Board of Directors for the Society of Emergency Medicine Physician Assistants.