Physician Extender Programs

Preamble

A physician extender is a healthcare provider who is never the most responsible practitioner providing patient care. Physician extenders must always practise under the supervision of a licensed physician within an approved physician extender program.

Physician extender program goals and objectives include:

• ensuring a standardized accountability framework for the conduct of the physician extender;
• supporting an employment environment for physician extenders in Nova Scotia; and
• assisting in the provision of patient care in settings that can provide appropriate oversight, supervision and structure as outlined in this policy.

Section 8 (1)(f) of the Medical Act gives the College authority to oversee and approve such programs.

Purpose

This policy describes the requirements for all physician extender programs in Nova Scotia.

Scope

This policy applies to all relevant physician extenders. Specifically, for this policy, a physician extender is either an Associate Physician on a Clinical Assistant licence or a Physician Assistant.  Associate Physicians are physicians and regulated by the College while Physician Assistants are not physicians and not regulated by the College.

Policy

Physician extender programs must assure uniform standards of qualifications and a minimum level of competency for all physician extenders.

Program Requirements

1. There must be a mechanism to ensure that all physician extenders have appropriate qualifications and have been properly credentialed within the institution.
   • Physician Assistants must hold appropriate certification with either the Physician Assistant Certification Council of Canada¹ or the National Commission on Certification of Physician Assistants (USA)².
   • Please refer to the policy for Clinical Assistant Licence³ for the eligibility requirements for Clinical Assistants.
   • All Associate Physicians must hold a Clinical Assistant licence with the College.
   • All Associate Physicians must have appropriate privileges through the Credentials Committee of Nova Scotia Health or the Izaak Walton Killam (IWK) Health Centre.
   • All physician extenders must have medical liability protection.

2. It is the responsibility of the Physician Extender Program to determine if any of the following are required for physician extenders:
   • Advanced Cardiac Life Support (ACLS) certification. 
   • Pediatric Advanced Life Support (PALS) certification.
   • Neonatal Resuscitation Program (NRP) certification.

3. There must be a probationary evaluation of all physician extender candidates at initial entry into a program or when the physician extender moves to another program in another discipline.
   • All physician extender candidates must undergo and satisfactorily complete a probationary period of 12 weeks. The physician extender will be evaluated with respect to their competence to perform the role of a physician extender in the intended clinical discipline.
   • During the probationary period, the physician extender candidate must be under the supervision of a clinical supervisor who is a staff physician with privileges within the department in which they will be practising.
   • The evaluation of a physician extender candidate during the probationary period must be directed by the physician extender Program Director.
   • The evaluation is not limited to but must include the assessment of:
     1. basic clinical skills;
     2. communication skills;
     3. the ability and willingness to function as a member of a clinical team;
     4. special knowledge and skills applicable to the intended clinical placement;
     5. clinical decision-making and the appropriate use of clinical and diagnostic resources;
     6. prescription writing;
     7. clinical documentation; and
     8. procedures required for the position which may evolve over time and requires demonstrated competence for each procedure.

4. There must be appropriate supervision of all physician extenders.
   • Each physician extender must be supervised by a clinical supervisor who is the most responsible physician and holds active staff privileges.
   • A clear description of the roles and responsibilities of the physician extender must be documented and available to the supervising physician, physician extender, physician extender Program Director and Department Head, and form part of the permanent record of the physician extender.
   • The clinical supervisor shall:
     • not delegate to a physician extender a duty or responsibility for which the physician extender is not adequately trained;
     • not delegate to a physician extender a duty or responsibility the clinical supervisor is not competent to perform themselves;
     • provide daily onsite, direct or indirect supervision;
     • not permit a physician extender to provide medical services in an area in which the clinical supervisor does not provide services.

5. There must be a Program Director for all physician extender programs.
   • There must be a physician extender Program Director appointed within each division in which physician extenders are employed. In the case of a small clinical division, the physician extender Program Director may be shared with another division. The physician extender Program Director is responsible for the following:
     • Assigning physician extenders to various services or duties within the division;
     • Assigning on-call duties;
     • Obtaining feedback and evaluations from clinical supervisors and colleagues including nursing and allied healthcare staff;
     • Maintaining a record for each physician extender;
     • Supervision, training, certification and recertification in procedures required to perform their role;
     • Advise the College if a Clinical Assistant is no longer working within the program;
     • Ensuring completion of evaluations;
     • Providing formal and informal feedback to physician extenders; and
     • Participating in periodic College Accreditation Surveys.
   • The physician extender Program Director is accountable to the College for the actions of physician extenders in the course of their employment within the hospital or health authority. The Program Director may recommend an alternate to perform the duties of Program Director during absences such as vacations, sabbaticals, etc.
   • There must be evidence that the clinical supervisor reviews the clinical work of the physician extender on a daily basis.

6. There must be an evaluation process to periodically assess the performance of all physician extenders.
   • The physician extender Program Director must evaluate each physician extender’s performance on at least a six-month basis and provide a written summary of the evaluation to the physician extender and to the Department Head. The physician extender Program Director and clinical supervisor should provide verbal feedback to the physician extender on an on-going basis throughout the year.
   • The evaluation must address the defined roles and responsibilities of the physician extender.
   • The periodic formal evaluation and the on-going feedback should form the basis for the continuous professional development needs for the physician extender.
   • Copies of the formal evaluations and any interim evaluations must be maintained in the physician extender’s file and be available for review.

7. There must be a process to document demonstrated competence for all procedures performed by all physician extenders.
   • There must be a well-documented process in place to certify the competence of any procedure to be performed by the physician extender.
   • The process must include appropriate training, demonstration and maintenance of competence.

8. There must be opportunities for all physician extenders to engage in continuous professional development.
   • There must be opportunity for the physician extender to attend clinical rounds and other educational sessions as their clinical responsibilities permit.
   • Educational resources (e.g. hospital/departmental library) must be available to the physician extender.
   • Physician extenders must participate in continuing professional development at a minimum of 50 hours per year.
   • There must be a mechanism to monitor and report on each physician extender’s participation in continuing professional development.
   • The Program Director must provide the College confirmation of all continuing professional development activities for Associate Physicians annually.
   • Physician Assistants must maintain certification and satisfactorily participate in continuing professional development to the satisfaction of the Program.

9. There must be a process in place for managing patient safety concerns, professional conduct and conflict issues.
   • As Associate Physicians on a Clinical Assistant licence are regulated by the College, there is always the College’s complaints process available. Such concerns must be managed by the Health Authority for all Physician Assistants.

10. There must be periodic satisfaction surveys completed by all physician extenders.
    • At least on a yearly basis the institution must conduct a written satisfaction survey by all physician extenders. The survey must address, but not be limited to: supervision, evaluation (formal or informal), certification of procedures, opportunities for continuous professional development, working environment, collegial working relationships with members of their clinical team.
    • The surveys must be maintained in a central file for review as necessary.
    • There must be evidence that significant and/or repetitive concerns expressed by the physician extenders or the department are addressed in a timely manner with outcomes documented.

Accountability Framework

Required components include:

1. A detailed job description for physician extenders within each clinical program;
2. Clear guidelines for delegation of the performance of procedures, including training leading up to demonstration of competence, as determined by the physician extender Program Director. Any procedure(s) not specified in the physician extender’s approved job description will require evidence of training, demonstration and maintenance of competence by the clinical program and approval by the physician extender’s Program Director; and
3. Evidence of adequate supervision, including the co-signing of hospital orders and prescriptions (as appropriate) as well as documentation of the physician extender’s attainment of the various levels of responsibility.

Resources

1. Physician Assistant Certification Council of Canada
2. National Commission on Certification of Physician Assistants
3. Clinical Assistant Licence

A Health Authority may put forth a proposed Physician Extender Program. Please contact the Registration Department for a link to the application form at registration@cpsns.ns.ca.