The following best practice was identified through CRICO/RMF’s “Office Practice Evaluation Program.” Since 1998, the foundation has evaluated hundreds of Harvard-affiliated ambulatory sites, through on-site chart reviews and interviews with staff.
Office practices that use advanced practice nurses and physician extenders need a way to ensure that these personnel get adequate supervision and decision-making support. Specific regulations and licensing requirements can vary by state. Individual practices should develop policies in accordance with their local rules, and affiliated hospitals may be a resource.
In the Harvard medical system, Jennie Wright is the project manager of the CRICO/RMF office practice evaluation program. Wright says that practices without enough structure in their supervision arrangements can struggle.
“I think when you go totally on an informal basis, you don’t have that supporting structure in place that sort of provide some parameters for discussion, provides a venue and a mechanism for discussion... Somebody catches you on the fly. You don’t really have adequate time to process the information and you don’t also have time to really gauge how comfortable they are with their own decision-making processes.”
Instead, Wright recommends drawing up a basic framework that provides objectivity and assigns the time for appropriate supervisory interaction.
“We find that some of the larger practices have an infrastructure, and sometimes even at smaller practices. Physicians and nurse practitioners will actually set aside a certain period of time, say once a week or once every other week, and actually take an hour, block it off, pull records, review the charts and discuss why the decision to treat was made in a particular way or not.
“While that’s important, it is also important that the physician be available if there is a question or a concern that the nurse practitioner does have on the fly. It doesn’t minimize the necessity of always being able to have somebody else to help you review, but it does provide another layer of supervision and hopefully comfort from both sides.”
