How to Onboard Advanced Practice Providers to Enhance Care and Reduce Risk

October 13, 2023
Failure to diagnose heart disease leads to death

A 55-year-old man with complaints of shortness of breath, fatigue and leg swelling was examined by a physician assistant (PA) at his family medicine clinic. The PA noted the man’s history of asthma, high cholesterol, diabetes and hypertension. The man admitted to the PA that he was noncompliant with his diet and medication. The PA documented the man’s blood pressure was high, his blood sugar level elevated and that his chest X-ray was abnormal. The PA diagnosed acute heart failure and unstable diabetes. He changed the man’s blood pressure medication, added a diuretic and instructed the man to follow up in the next week.

At the follow-up appointment, the patient was still complaining of shortness of breath and leg swelling. The PA documented that his blood pressure and blood sugar levels were still elevated but noted that the chest X-ray seemed to be improved. The PA discontinued the diuretic and added an asthma medication for the shortness of breath. For both visits, there was no discussion with, or review by, the PA’s supervising physician.

Two days later, the patient was found unresponsive at home by his wife and died on the way to the hospital. The cause of death was listed as undiagnosed ischemic heart disease. His family filed a malpractice claim against the PA. The assigned physician supervisor and the clinic as the employer—two parties who never laid hands or eyes on this patient—were also named in the suit. The expert reviews of the care were not supportive, and the case was settled with a payment to the family.

Advanced practice provider employment is increasing

According to the Association of American Medical Colleges (AAMC), the U.S. faces a projected shortage of up to 124,000 physicians by 2034, with demand outpacing supply. The employment of advanced practice providers (APPs), which includes nurse practitioners (NPs) and physician assistants (PAs), to fill these roles is increasing. The U.S. Bureau of Labor Statistics predicts a 40% growth in NP roles and a 28% growth in PA roles between 2021 and 2031.

Does employment of APPs increase risk?

In an analysis of our malpractice claims involving APPs, diagnostic error is the costliest and most frequent allegation. When we analyzed the cases involving APPs, we found that the allegations made against these providers were the same as the allegations made against physicians in the same specialty practice areas. The top three specialties involving APPs claims were family medicine, orthopedics and obstetrics.

The clinical review of these APP cases demonstrates team-related vulnerabilities including:
• Clinical judgment factors due to insufficient mentoring and collaboration opportunities with physicians
• Communication breakdowns among the care team due to the absence of teamwork training and skills
• Administrative issues, typically inadequate physician oversight, failing to clarify roles and a lack of an APP policy

A professional negligence or malpractice lawsuit involves four basic elements:

  1. Duty of care to the patient
  2. Breach of that duty or breach of the standard of care
  3. Injury or damages suffered by the patient
  4. A causal link between the breach of duty and the injury or damages

Things get tricky, however, when a physician or facility was not involved with the patient’s care but was still liable for hiring, credentialing or supervising the APP who provided the care (like in our case example). Employers can be liable for their care team members’ negligence under the theory that they are able to manage the employee’s work. Employers can also be liable for negligent hiring or credentialing if they fail to verify training or monitor performance. Supervising physicians can be liable when they collaborate in or supervise a care plan, or when they should have collaborated or supervised but failed to do so.

How to onboard APPs to enhance care and reduce risks

Understanding individual APP needs is important for proper implementation of your organization’s onboarding program and to reduce risk. A comprehensive onboarding program should include these components:

  1. Structured orientation plan. A successful onboarding process begins with a well-structured orientation plan that considers the individual APP’s needs.
  2. Mentorship or preceptorship opportunities. Pair new-to-practice or less experienced APPs with skilled mentors or preceptors.
  3. Collaborative training. Incorporate joint training sessions where APPs, physicians, nurses and other team members discuss cases, share insights and collaborate on care protocols.
  4. Continuous professional development. Regular educational sessions ensure that APPs maintain their skills and knowledge, which reduces the probability of patient harm.
  5. Clearly defined clinical scope of practice and supervision requirements. Clearly define state-specific scope of practice and prescribing authority, clinical responsibilities, collaborative practice agreement requirements and levels of physician oversight. Outline what patient presentations require a consult or collaboration with a physician.
  6. Team-based care model. Utilize a team-based care model and include regular physician collaboration opportunities.
  7. Effective communication training, formal processes and tools. Breakdowns in communication among the care team are often a contributing factor to patient harm and malpractice claims. Implement formal teamwork training, regular case discussions, consultations, and interdisciplinary meetings where APPs and physicians can make collaborative care decisions.
  8. Clinical oversight and peer review. Implement a system of physician oversight and peer review to ensure quality patient care. Regularly review patient cases, treatment plans and documentation to identify areas for improvement and address any concerns promptly.
  9. Regular performance feedback. Establish a feedback loop that includes case-specific feedback and regular performance evaluations. Constructive feedback helps APPs understand their strengths and areas for improvement.
  10. Quality improvement initiatives and risk management education. Engage APPs in quality improvement initiatives aimed at enhancing patient care and improving safety.

Watch the on-demand webinar Onboarding Advanced Practice Providers to Enhance Care and Reduce Risk—to learn more about onboarding APPs to enhance care and reduce risk.

Risk reports

Our risk reports analyze malpractice claim data on a variety of topics and specialties, including APPs, family medicine, surgical specialties and obstetrics. Each risk report shares insights to help reduce harm events and malpractice claims.

Are you a client? Sign in to MyAccount to access exclusive client versions of our risk reports. The expanded risk reports share actionable insights and strategies you can utilize to help reduce harm events and malpractice claims. After you sign in to MyAccount, follow Risk Resources > Tools & Resources > Publications > Risk Reports. You also have access to a host of Bundled Solutions (in Risk Resources) that cover a wide variety of topics to assist you in your risk mitigation efforts.

Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.

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