Best Practices for Hiring and Making Use of Nurse Practitioners, Physician Assistants

As the number of these nonphysician providers (NPPs) burgeons, the supply of physicians shrinks significantly. According to the Association of American Medical Colleges (AAMC), the United States will face a shortage of up to 90,000 physicians in the next 10 years.

To reduce physician workload and fill gaps in the physician shortage, many healthcare organizations are hiring more NPPs.

Nurse practitioners (NPs) and physician assistants (PAs) give patients the same standard of care. They practice in all 50 states and Washington, DC, with some regulations differing by state. PAs earn a bachelor’s degree followed by a master’s in physician assistant studies, health or medical science. NPs are nurses with advanced clinical training who have earned a master’s or doctorate degree.

Depending on state jurisdiction, both practice under the supervision or in collaboration with a physician, who has vastly more education, knowledge and experience. An uptick in errors and litigation among NPPs, however, may indicate they are not being vetted properly at hiring, nor supervised closely enough on the job.

If a claim or lawsuit results from an NPP’s care, the supervising physician and the practice itself usually are made party to the action. Depending on state jurisdiction, malpractice allegations may take one of several forms: vicarious liability, negligent supervision, negligent hiring/retention or lack of informed consent, typically stemming from the patient’s belief that he or she was treated by an actual physician.

Consider this North Carolina case: A 36-year-old pregnant patient receiving prenatal care at a women’s health center from an NP and a medical doctor (MD) asks the NP about amniocentesis. The NP explains it is a very dangerous procedure and does not refer the woman to anyone to discuss amniocentesis. Later in the pregnancy, the MD examines the patient, who again raises the subject of amniocentesis. The MD says 37 is the age at which Down syndrome is a concern and both the physician and patient drop the topic. After birth, the baby is diagnosed with Down syndrome.

The patient sues the NP and MD, claiming they failed to properly advise her on amniocentesis and genetic counseling. If properly advised, the patient claimed she would have had amniocentesis, it would have revealed the fetus had Down syndrome and she would have terminated the pregnancy. Eventually, since he met the patient personally, the MD was found liable because he breached the standard of care—i.e., at 36-37 years of age, amniocentesis is indicated if the patient expresses high concern. The NP was not held liable because the patient testified at trial that she was still determined to get the amniocentesis after her conversation with the NP.

This case illustrates the physician’s overall responsibility for guiding NPPs in caring for patients and how establishing a duty of care directly with an NPP’s patient may make the physician especially culpable.

Scrupulous hiring and supervision are crucial for reducing compliance risk and maintaining quality patient care. Before hiring an NPP, physicians first must assess whether they have the time and temperament for supervision, because at least initially it will increase the workload. A physician’s lack of accessibility and approachability may lead NPPs to avoid and work around him, possibly acting beyond their scope of practice and increasing liability exposure.

In hiring NPPs:

• Know and follow state licensing laws and regulations concerning the use and supervision of NPPs to determine what type (e.g., NP or PA) is needed;
• Create a job description;
• Even if not required by law, obtain and tailor a supervisory/collaborative agreement, delineating duties, practice protocols, authority limits and the supervisor’s role; and
• Verify candidates’ credentials, including education, licensing status and board complaints, certification, continuous education (CE) hours, employment and malpractice history, credit and criminal background checks.

To promote a healthy practice:

• Introduce staff to NPPs and clarify their involvement in patient care;
• Train front office staff to stipulate patient appointments are with NPPs;
• Post NPP roles in brochures and websites;
• Ensure NPPs wear name tags with their credentials;
• Correct those who refer to NPPs as “doctor”;
• Review regularly and sign off on, but don’t co-sign, NPP records (“reviewed by” or “under the supervision of”); and
• Allow patients who insist, to be seen by a physician.

NPPs are not a panacea for solving the physician shortage. If vetted properly at hire and managed effectively, however, NPPs can be valuable assets, helping reduce workload and improving patient satisfaction and outcomes.