Some of the most important risk areas related to advanced practice providers (APPs) or mid-level providers include: credentialing, scope of practice, communication, and supervision.

First, with respect to credentialing, providers have different backgrounds, experience and training, so it is critical to have a formal credentialing process that includes orientation, proctored shifts and review of documentation. Also, the scope of practice for APPs is quite variable in emergency medicine today. APPs are being used in fast tracks, wound care centers, urgent care centers, and the main emergency department.

Adequate communication is essential to successful risk management. Communication and hand-offs must be addressed, as they are frequently identified as the cause of errors in patient care. Also, APPs should be kept in the loop of departmental meetings, peer review, hospital updates, and changes in policies and procedures or practice guidelines.

When left out of the loop, APPs may feel that they practice in isolation from their physician colleagues. Also, as health care changes, roles for certain APPs may expand, causing changes, and therefore increased risk, in the supervision of APPs. States may have clear regulations regarding scope of practice, appropriate supervision, and staffing ratios.

In some states, certain APPs may work independently, while in other states they are expected to work closely with their physician colleagues. State regulation may mandate differing degrees of supervision for varying types of APPs. As regulatory efforts regarding supervision increase, effective compliance programs should reflect the changes in the supervision requirements to reduce risk, as inadequate supervision can result in diagnostic error and delayed treatment or other allegations of negligence.

Case Study: The patient presented to the ED with a headache and was diagnosed with a sinus infection by the APP. The patient was placed on antibiotics. The patient returned a few days later with a subarachnoid hemorrhage. In this case, the APP had not passed his boards and was not licensed. It was later reported that the physician was using this APP as a scribe but allowed him to see the patient. This shows failures on many levels: verification of the provider’s credentials, assurance that work was within scope of practice, and proper supervisory oversight.

Case Study II: A patient presented to the ED complaining of back pain and left arm discomfort. The patient was examined by the APP and, based on the fact that the pain was relieved by medication that he felt would not relieve cardiac pain, received a diagnosis of musculoskeletal pain and muscle spasms. The APP did not realize the patient had experienced an acute coronary event.The patient was discharged with prescriptions for pain medication and muscle relaxants. The APP did not consult with the supervising physician in a timely manner, and the physician did not review the medical chart until the following day. Unfortunately, the patient by then died of a heart attack. This illustrates that the supervising physician should be available at all times for consultation and should encourage consultation in high-risk complaints, even if not mandated by regulations, policies, and procedures.

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.