From the Tennessee Medical Association website, www.tnmed.org
As of March 20, 2018, the Tennessee Board of Medical Examiners (BME) has updated its policy from January 2002 addressing a supervising physician’s responsibilities for medical service tasks delegated in a physician’s office to personnel other than APRNs and PAs. Although as of May 18, 2018, both policies were posted on the BME website, TMA believes that the 2018 policy replaces the 2002 policy since they cover the same subject matter and personnel (RNs, LPNs, Medical Assistants, and unlicensed persons). Some requirements go away, some clarified, and new ones are added.
These requirements from 2002 are no longer in the updated policy:
- A physician must have an unencumbered medical license in order to qualify to supervise;
- A supervising physician be “on site” four hours per week;
- Protocols must be updated annually (it was changed to every two years);
- Medical records be reviewed and signed off on every seven days; and
- A back-up supervisor is identified in the protocols.
The new policy clarifies that the supervising physician is responsible for the performance of delegated tasks.
The new policy also attempts to clarify that supervisees may not be used to expand services beyond which the supervising physician has competence. The 2002 policy conveyed this intent but was defined by specialty board certification. The 2018 policy clarifies that the supervising physician must “customarily perform the delegated medical service as part of his or her medical practice and not exclusively by delegating the service to an employee” and further states the delegated task must be “within the delegating physician’s expertise and training.” Having a lactation consultant in a pediatric office would be allowable; having an unlicensed person do Botox injections in a psychiatrist office would likely be prohibited.
The policy clarifies what tasks may be delegated. It allows for the delegation of services that are “routine and technical in nature” and TMA interprets this to apply to unlicensed persons with no scope of practice. The policy allows for the delegation of tasks within the scope of practice of a licensed supervisee.
The 2018 policy clarifies to whom a task may be delegated. It prohibits supervising physicians from delegating tasks which are limited to a licensed individual. TMA believes it means delegating tasks exclusively limited to licensed individuals to unlicensed individuals or persons licensed but not licensed for that particular task. This might be nursing tasks on which the Board of Nursing has policy that only RNs can perform. This is included despite a statute in the Nurse Practice Act that excludes “persons employed in the office of a licensed physician”… assisting in nursing care of patients where adequate medical or nursing supervision, or both, is provided.” Physicians are advised to follow the BME’s policy.
Other notable updates in the new policy:
- The BME will presume that, in the absence of documentation of the delegation, if a supervisee is performing a medical service task in a physician office, the task was delegated by the supervising physician;
- The supervisee’s qualification and competence to perform delegated tasks must be documented (the policy lists ways to do this); and
- That a risk to the patient assessment be conducted prior to the assignment of tasks that are not “routine or technical in nature.”
Throughout the policy the BME uses the term “employee” but the TMA legal department opines that such responsibility would include the performance of independent contractors or any supervisee in the office except an APRN or PA.
Supervision, now called “collaboration,” with APRNs is governed by Rule 0880-06 and PAs by 0880—02-.18.
Physicians with concerns about their current delegation arrangements may discuss them with TMA legal department staff, or they may obtain a private advisory ruling from the BME. TMA members can receive assistance from the TMA legal department making advisory ruling requests, firstname.lastname@example.org.