Physician supervision of a physician assistant, amendments to ch 21
Notice of Intended Action
Twenty-five interested persons, a governmental subdivision, an agency or association of 25 or more persons may demand an oral presentation hereon as provided in Iowa Code section 17A.4(1)"b."
Notice is also given to the public that the Administrative Rules Review Committee may, on its own motion or on written request by any individual or group, review this proposed action under section 17A.8(6) at a regular or special meeting where the public or interested persons may be heard.
Pursuant to the authority of Iowa Code section 147.76, the Board of Medicine hereby proposes to amend Chapter 21, "Physician Supervision of a Physician Assistant," Iowa Administrative Code.
The purpose of Chapter 21 is to establish factors that would render a physician ineligible to supervise a physician assistant. The proposed amendments establish that a physician is ineligible to supervise a physician assistant if the physician does not have a written supervisory agreement in place with each physician assistant supervised by the physician.
The Board approved this Notice of Intended Action on April 28, 2017.
Any interested person may present written comments on the proposed amendments not later than 4:30 p.m.on June 13, 2017. Such written materials should be sent to Mark Bowden, Executive Director, Board of Medicine, 400 S.W. Eighth Street, Suite C, Des Moines, Iowa 50309-4686; or sent by e-mail to firstname.lastname@example.org.
There will be a public hearing on June 13, 2017, at 9 a.m.at the Board's office, 400 S.W. Eighth Street, Suite C, Des Moines, Iowa, at which time persons may present their views either orally or in writing.
After analysis and review of this rule making, no negative impact on private sector jobs and employment opportunities within the state of Iowa has been found. Other than requiring a written supervisory agreement on a simple form approved by the Board, the essential elements of the supervisory agreement are existing requirements found in the Iowa Code and Iowa Administrative Code.
These amendments are intended to implement Iowa Code chapters 147, 148 and 272C.
The following amendments are proposed.
Item 1. Adopt the following new subrule 21.1(3):
21.1(3) The physician does not have a written supervisory agreement in place with each physician assistant supervised by the physician.
Item 2. Amend rule 653—21.3(148) as follows:
653—21.3(148) Board notification. A physician who supervises a physician assistant shall notify the board of the supervisory relationship within 30 days of the provision of initial supervision and at the time of the physician's license renewal.
Item 3. Renumber rules 653—21.4(148,272C) to 653—21.7(17A,147,148,272C) as 653—21.5(148,272C) to 653—21.8(17A,147,148,272C).
Item 4. Adopt the following new rule 653—21.4(148,272C):
653—21.4(148,272C) Supervisory agreements. Each physician who supervises a physician assistant shall, using a form approved by the board, establish a written supervisory agreement prior to supervising a physician assistant. The purpose of the supervisory agreement is to define the nature and extent of the supervisory relationship and the expectations of each party. The supervisory agreement shall take into account the physician assistant's demonstrated skills, training and experience, proximity of the supervising physician to the physician assistant, and the nature and scope of the medical practice. The supervising physician shall maintain a copy of the supervisory agreement and provide a copy of the agreement to the board upon request. The supervisory agreement shall, at a minimum, address the following provisions.
21.4(1) Review of requirements. The supervisory agreement shall include a provision which ensures that the supervising physician and the physician assistant review all of the requirements of physician assistant licensure, practice, supervision, and delegation of medical services as set forth in Iowa Code section 148.13 and chapter 148C, this chapter, and 645—Chapters 326 to 329.
21.4(2) Assessment of education, training, skills, and experience. The supervisory agreement shall include a provision which ensures that each supervising physician assesses the education, training, skills, and relevant experience of the physician assistant prior to providing supervision. Each supervising physician and physician assistant shall ensure that the other party has the appropriate education, training, skills, and relevant experience necessary to successfully collaborate on patient care delivered by the team. Thereafter, each supervising physician shall regularly evaluate the clinical judgment, skills, performance and patient care of the physician assistant and shall provide appropriate feedback to the physician assistant.
21.4(3) Delegated services. The supervisory agreement shall include a provision which addresses the services the supervising physician delegates to the physician assistant. The medical services and medical tasks delegated to and provided by the physician assistant shall be in compliance with 645—subrule 327.1(1). All delegated medical services shall be within the scope of practice of the supervising physician and the physician assistant. The supervising physician and the physician assistant shall have the education, training, skills, and relevant experience necessary to perform the delegated services prior to delegation.
21.4(4) Communication. The supervisory agreement shall include a provision which sets forth expectations for communication. Each supervising physician and physician assistant shall communicate about and consult on medical problems, complications, emergencies, and patient referrals as indicated by the clinical condition of the patient. The supervising physician shall be available for timely consultation with the physician assistant, either in person or by telephonic or other electronic means.
21.4(5) Chart review. The supervisory agreement shall include a provision which sets forth the plan for completing chart reviews. Each supervising physician shall conduct and document an ongoing review of a representative sample of the physician assistant's patient charts encompassing the scope of the physician assistant's practice provided under the physician's supervision and shall discuss the findings of the reviews with the physician assistant.
21.4(6) Face-to-face meetings. The supervisory agreement shall include a provision which ensures at least two face-to-face meetings with each supervising physician and physician assistant annually. If the physician assistant is practicing at a remote medical site pursuant to rule 645—327.4(148C), the biweekly visits may be used to satisfy this requirement. The meetings are for the purpose of discussing topics deemed appropriate by the physician or the physician assistant, including supervision; expectations for both parties; assessment of education, training, skills, and relevant experience; review of delegated services; review of the medical services provided by the physician assistant; and the types of cases and situations when the supervising physician expects to be consulted. The supervising physician shall ensure that the face-to-face meetings are documented.
21.4(7) Remote medical site. The supervisory agreement shall include a provision which ensures that the supervising physician visits a remote medical site to provide additional medical direction, medical services and consultation at least every two weeks or less frequently as specified in unusual or emergency circumstances. When visits are less frequent than every two weeks in unusual or emergency circumstances, the physician shall notify the board in writing of these circumstances within 30 days. "Remote medical site" means a medical clinic for ambulatory patients which is away from the main practice location of a supervising physician and in which a supervising physician is present less than 50 percent of the time when the remote medical site is open. "Remote medical site" will not apply to nursing homes, patient homes, hospital outpatient departments, outreach clinics, or any location at which medical care is incidentally provided (e.g., diet center, free clinic, site for athletic physicals, jail facility). The board shall only grant a waiver or variance of this provision if substantially equal protection of public health, safety, and welfare will be afforded by a means other than that prescribed in this rule.
21.4(8) Alternate supervision. The supervisory agreement shall include a provision which sets forth the expectations and plan for alternate supervision. If the supervising physician will not be available for any reason, an alternate supervising physician must be available to ensure continuity of supervision. The supervising physician will ensure the alternate supervising physician is available for a timely consultation and will ensure that the physician assistant is notified of the means by which to reach the alternate supervising physician. The physician assistant may not practice if supervision is unavailable, except as otherwise provided in Iowa Code chapter 148C or 645—Chapters 326 to 329.
Item 5. Adopt the following new subrule 21.5(4):
21.5(4) The physician fails to adequately direct and supervise a physician assistant or fails to comply with the minimum standards of supervision in accordance with this chapter, Iowa Code section 148.13 and chapter 148C, and 645—Chapters 326 to 329.