How Delineating Privileges Can Offset Risks of Private Practice Staff Misuse

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By Gigi Alcevedo-Parker 

There’s a proliferation of medical assistants in ambulatory healthcare these days, and small wonder.  

Medical economics make them important assets for any medical office. Trained to perform administrative, clerical and even some clinical tasks, they are shouldering a widening variety of work in medical offices.  

But too often they’re delegated tasks that cross the line of what they are actually permitted, under law, to perform. The rules over what medical tasks a physician may delegate and to whom diverge dramatically from one state to the next. Even so, when a non-medical professional is put in the position of practicing medicine – diagnosing, treating, operating or prescribing – the professionals in the office face a very real liability risk.  

One way to guard against the increasing blurring of roles is borrow from the credentialing process in hospitals: delineate and formally document the scope of practice for all medical staff in private medical offices, and communicate it well. 

The growing reliance on medical assistants 

By 2020, the number of medical assistant jobs had expanded to nearly 721,000 (76% in ambulatory care), with an 18% growth rate projected through 2030[1].  

A large multi-specialty medical group might employ 50 physicians, one registered nurse and 35 medical assistants. Physicians might well be willing to perform some more routine medical services – give a flu shot in the primary care office or insert a cannula in the urology clinic. They more typically delegate them, though, to the professional nurse.  

But does that one nurse have sufficient bandwidth to add more activities to his or her existing responsibilities? Probably not. Nor are those medical assistants necessarily allowed to step in take up the slack on most medical tasks. 

But they increasingly are.  

A welter of rules 

In highly regulated states (New York and Massachusetts) no licensed medical professional, including physicians, may delegate any medical tasks. In less regulated states (Illinois and Wisconsin), physicians may delegate a “reasonable” scope of administrative and clinical tasks to unlicensed, but knowledgeable and competent, professionals. The least regulated states (Wyoming, Missouri) place no delegation limits on physicians, physician assistants or nurses, including to medical assistants. Nor are they required to be certified or trained. 

It’s a small wonder, given divergent “scope of practice” provisions, that roles are blurred. Medical assistants may be delegated the task of drawing blood…but they must be trained in phlebotomy. They may be allowed to administer flu shots, but not medications given their lack of training in pharmacology.  

Where the line is drawn in delivering medical services is when when professional medical or nursing judgments come into play.  

In one instance, an unlicensed medical assistant was answering phone calls and triaging patient concerns. When a patient described radiating pain from her flank and back, bleeding[1]  and bowel movement changes, the assistant assumed the issue was a urinary tract infection. Medical professionals were not informed. And the patient died when the complications became life-threatening. 

Why delineation of privileges can offset the risks 

The inappropriate use of staff raises numerous risks. It’s feasible that mistakes aren’t covered by the medical professional liability policy, and resulting regulatory repercussions could to fines and higher medical malpractice insurance rates. And a payer could act to recoup payments if it believed coding for the care was inaccurate, alleging falsification. 

The hospital credentialing process serves as a good model for delineating privileges. Under it,  physicians have strict admitting rights that specifically delineate their privileges. For example, an OB/GYN and neurosurgeon cannot use equipment approved for each other’s use. 

Private medical offices can easily borrow the approach, applying it to all medical staff – physicians to physician assistants, nurses at all levels and medical assistants. The delineation of privileges offers a clear understanding of each professional’s scope of responsibilities, and also advances a better understanding of the roles of certified and non-certified medical assistants.  

The information charted out would establish minimal years of education for each level of medical professional, and list the tasks (general practices as well as specialties) each may perform.  

In general practices, for example, e-prescribing, including refills, are delineated privileges of medical doctors, advanced practice registered nurses and physician assistants. They are not, however, privileges allowed registered nurses, licensed practical nurses or medical assistants. Triaging calls from sick patients and providing immunizations would be privileges for all but medical assistants. 

By initiating this approach, the private practice demonstrates an expanded level of care in managing who can delegate what medical tasks in the interests of optimal patient outcomes. It won’t totally eliminate the downside risks of staff misuse, but will help. 

About the author:
Gigi Acevedo-Parker is National Practice Leader – Critical Risk Management, for global insurance brokerage Hub International. 

She is a nurse executive with more than 30 years as a healthcare clinician, nursing leader, healthcare consultant and educator with a focus on healthcare risk mitigation and patient safety. Gigi has deep experience in many diverse aspects of risk management and compliance, including loss prevention and mitigation, patient safety and quality, claims and litigation management, corporate compliance and privacy.  


[1]    https://www.bls.gov/ooh/healthcare/medical-assistants.htm