Part 3 - Professional Services
Chapter 28 - Physicians Assistants
- Purpose. The purpose of this chapter is to:
- establish minimum Physician Assistant (PA) qualifications for employment in the Indian Health Service (IHS) and
- establish the IHS policy for national standards of practice for PAs
- Background. Because State laws governing PA standards of practice vary significantly, it is necessary to establish an IHS national scope of PA practice. The national scope of practice will provide basic guidance and reduce the complexity of monitoring multiple State regulations.
The IHS has long required national certification by the National Commission on Certification of Physicians Assistants (NCCPA) for all positions in the GS-603 series.  A one year grace period for new PA graduates to obtain national certification while employed by IHS has been allowed, but is no longer justified or desirable. The certification examination was originally administered only on an annual basis. The NCCPA now offers eligible PA graduates the opportunity to take the PA national certification exam as early as seven (7) days after graduation, and throughout the year, at numerous testing locations nationwide.
- Policy. It is IHS policy to employ PAs to extend health services and improve the quality of medical care provided to American Indians and Alaska Natives (AI/AN) and to use physicians more effectively and efficiently. The IHS determines the scope of practice for PAs working for the IHS.
- Physician Assistant. A PA is a health professional who provides primary or specialty medical care in association with physician supervision. Such supervision may be available either on-site or remotely. Physician Assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services.
3-28.2 PROFESSIONAL CREDENTIALS
- Education. All PAs employed by the IHS must be graduates from one of the following:
- a PA training program that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (or a previously recognized accrediting body); or
- an IHS intramural PA training program in operation between 1971 -1 983. Graduates from this program may also be known as Community Health Medics (CHM).
- Certification. All PAs engaging in clinical practice are required, unless exempt, to possess at the time of employment current certification by the NCCPA and must maintain that certification throughout their employment with the IHS. Physician assistants who do not take the exam before their current certification expires or who do not pass the re-certification exam will immediately lose their clinical privileges and possibly their employment. However, the suspension of clinical privileges related to loss of certification shall be considered administrative and not constitute a reportable adverse action. Exemptions to maintaining current certification follow:
- All PAs and CHMs who were hired prior to February 1, 1990, if not currently certified, may remain in their present positions without NCCPA certification; however, they must become NCCPA certified in order to transfer to a new position and/or facility.
- All PAs who do not provide direct patient care may function in their administrative role without NCCPA certification. However, they must become NCCPA certified in order to regain clinical privileges.
- Recruitment of potential PA candidates is appropriate while individuals are completing the PA training program. Individuals may apply and be selected for a PA position before they graduate. However, they must graduate in good standing and obtain NCCPA national certification before they are offered a position.
- Continuing Medical Education. Continuing Medical Education (CME) is critical for sustaining clinical skills necessary for the PA to perform his/her duties. All PAs are required to obtain 100 hours of CME every 2 years in order to maintain NCCPA certification. Facilities are encouraged to provide the time and necessary funding as appropriate to ensure all assigned PAs remain current in their clinical skills.
- Licensure. While not required as a condition for Federal employment, State licensure may be locally required at an IHS site for billing purposes. The IHS recommends, but does not require, a PA to be licensed or certified by the State in which he or she intends to practice.
- Privileging. The facility director is responsible for ensuring that each PA is granted clinical privileges in accordance with that facility’s medical staff by-laws. The privileging statement will delineate the PA’s approved clinical functions and level of practice, as well as the physician’s clinical supervision of the PA. The PAs’ clinical privileges shall be commensurate with their education, experiences, competence, and operational needs for the service to which they are assigned.
- Clinical Supervision. All PAs hired, either as contractors or Federal employees, must have a supervising physician. The supervisory physician is the PAs primary clinical supervisor. But, as a member of the medical staff, the PA may consult with any physician present at any given time. The process by which a supervising physician is appointed shall be left to the discretion of the facility’s medical staff. The supervising physician will be responsible for the clinical oversight of the PA. This does not suggest that PAs are unable to exercise autonomous medical decision-making while providing patient care. The physician (appointed by name and in writing) must demonstrate the ability to provide the required professional supervision, guidance, and support that is of vital importance in all patient treatment settings.
- Physician/PA Relationship. Within the physician/PA relationship, the PA may exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. The PA may serve in a variety of medical and surgical specialty settings in addition to primary care settings, as with other medical staff members. In addition to direct patient care, the PA may also engage in clinical teaching, patient education, research, and administrative activities.
- Supervisory Physician. The degree of clinical supervision provided will be dependent upon the PA’s training, experience, and current competence. However, the physician is not required to be present at the place where the PA provides medical services. Physician assistants may practice at remote sites or after hours without a supervising or consultative physician on-site as long as the PA maintains verbal contact with the supervising physician. The supervising physician shall:
- Be qualified by education, training, and privileges to perform any treatment or procedure that he/she directs a PA to perform.
- Be responsible for the PA’s medical practice and the quality of care rendered.
- Be available for consultation in person, by telephone, by radio, or by any other means that allows person-to-person exchange of information. An alternate back-up physician supervisor must be available when the primary physician supervisor is absent. Any qualified physician staff serving within the service unit may be designated as back-up physician supervisor during the primary supervisor’s absence.
- Ensure that the PA’s practice remains within the scope of his or her clinical privileges.
- Monitor the PA’s clinical performance using established outcome criteria for treatment, referral, and follow-up care.
- Periodically review a representative sample of medical treatment records for patients managed by the PA at least every 3-4 months.
- Prescribing Privileges. Physician assistants provide care as agents of their supervising physician, and the supervising physician bears responsibility for the medical appropriateness and correctness of all orders. Prescriptive authority for inpatient and outpatient pharmaceuticals will be established through individualized clinical privileges. Prescriptions or medication orders written by PAs within their privileges will not require a physician co-signature. Prescribing privileges may include the following:
- writing prescriptions,
- writing or establishing inpatient orders (if so privileged),
- dispensing medications (as required by clinical setting and facility policy and procedures), and
- administering pharmaceuticals, where appropriate to do so.
- Prescribing Privileges for DEA Controlled Substances (Schedules II-V). Prescribing privileges for DEA controlled substances (Schedules II-V) may be granted to PAs in accordance with Part 3, Chapter 7,“Pharmacy,” Indian Health Manual:
- The facility has authorized the PA to dispense or prescribe designated schedules of controlled substances under its DEA registration or a personal DEA registration.
- The PA must be registered, licensed, or otherwise specifically recognized by any State authority in accordance with DEA requirements to prescribe designated schedules of controlled substances.
- The PA adheres to all local facility policies regarding the prescribing of controlled substances.
3-28.4 QUALITY MEASURES AND SCOPE OF PRACTICE
- Quality Assurance/Peer Review. Each PA is subject to the same quality assurance/peer review process that is used at the local level for all other health care providers.
- The clinical competence of PAs will be reviewed and documented at least annually and will include patient care review in accordance with local policies and procedures.
- In facilities where more than one PA is employed, PAs may participate in the review and evaluation of their peers' clinical performance.
- The review of prescribing practices shall be employed for PAs in the same manner as for other members of the facility's medical staff.
- Physician co-signature for PAs on medical records or prescriptions is not an IHS requirement but may be used for third-party billing purposes. Physician co-signatures for PAs may also be utilized on an individual basis, e.g., during the initial appointment or if clinical privileges have been restricted or reduced.
- National Scope of Practice. The PA National Scope of Practice includes but is not limited to the following duties:
- Routine Duties. Duties that are performed on a regular and repetitive basis:
- Perform initial and/or periodic histories and physical examinations.
- Provide and coordinate comprehensive care for assigned patients in any assigned care setting and in accordance with training and education.
- Manage acute, episodic, and chronic conditions occurring in assigned patients and refer patients when disease process exceeds the PA's education, training, and/or experience.
- Screen patients to determine the need for further healthcare.
- Order and interpret diagnostic studies such as laboratory tests, radiological exams, electrocardiograms, or other studies as appropriate and specified in each PA's clinical privileges.
- Carry out health promotion and disease prevention activities including education and shared decision-making.
- Provide appropriate periodic mental health assessment, screening, and counseling for mental illness, family violence, and diseases of addiction.
- Draw blood or obtain other specimens for laboratory testing as needed.
- Initiate and expedite requests for consultations and arrange special tests and studies.
- Write orders as necessary for the care of the patient in accordance with this chapter.
- Record progress notes and summaries in the patient’s medical record.
- Obtain informed consent and document performed procedures.
- Educate and counsel patients and families in preventive care, medical conditions, and the use of prescribed treatments and drugs.
- Prescribe and dispense medications and durable medical devices and supplies.
- Prescribe and dispense controlled substances within jurisdiction of the PA’s State license and facility policy.
- Perform excisions, biopsies, incision and drainage, laceration repairs, castings, and additional procedures in accordance with training and clinical privileges.
- If specifically privileged to provide inpatient care, make daily rounds to observe and record patient's medical progress; update and summarize medical records; change orders when appropriate; and notify the responsible physician of significant changes in a patient's condition. There must be documentation of consultation with the supervising physician. "Notes and Orders" do not routinely have to be cosigned. The PA may be delegated the task of documenting the discharge summary, but the supervising physician must write a discharge note, or cosign the discharge summary in accordance with the Joint Commission ot CMS standards.
- If specifically assigned to a surgical unit, perform first assistant, preoperative, perioperative, and postoperative care in accordance with their training and clinical privileges.
- Emergency Duties/Conditions. The PA initiates care for patients in life-threatening situations where a physician is not immediately available and makes every effort to summon a physician as soon as possible. All PAs are expected to obtain Basic Life Support, Pediatric Advanced Life Support, and Advanced Cardiac Life Support certifications as required by site policies. Examples of emergency duties include the following:
- Cardiopulmonary resuscitation.
- Advanced Cardiac Life Support and defibrillation.
- Treatment of acute respiratory failure.
- Treatment of life threatening traumatic injuries.
- Identification evaluation, and initiation of appropriate treatment to stabilize patients presenting with any life threatening or medically urgent injuries, illness, or conditions.
- Performance of all diagnostic and therapeutic emergency medical procedures for which he or she has been properly trained and privileged.