Establishing and growing the scope of practice of physician assistants

Assessment of PAs

Our clinical group has developed a process to address the challenge of establishing a PA’s competencies and corresponding scope of practice. We are a group practice of 8 rural Ontario physicians who, in 2009, began incorporating PAs into our clinic with the goal of engaging them in the broadest scope of primary care services possible. As this type of health care worker was a new entity for us, and was going to practise under our licences, there was much more concern and focus on determining the PA’s competence compared with independent health professionals such as nurses and nurse practitioners. Our goal was to create an evaluation method that would make all the physicians in the group confident in the outcome.

In our process a new PA starts with a 2-month orientation and evaluation period in which every patient he or she visits in the clinic is also seen by the supervising physician of the day or the case is discussed with the supervising physician before the end of the patient visit.

Using a form that we have created (available at CFPlus^*), the PA then records the medical issues that he or she has managed, any prescriptions that have been initiated, or any investigations that have been ordered. At the end of the clinic, the supervising physician scores the PA’s skill level in managing the presenting complaints, as well as in initiating medications and ordering diagnostic and laboratory tests, from 1 (requiring full support) to 5 (working independently). These assessment forms are collected and the information is compiled. At the end of the 2-month period, we conduct a PA review in which the PA’s competencies are determined based on the information from these assessment forms. Once a PA has 3 consecutive scores of a level 4 or higher for visits regarding the same clinical problem, he or she is deemed competent in that responsibility. When the evaluation findings reveal that the PA successfully managed the clinical problems, correctly used the laboratory or diagnostic tests, and appropriately initiated medications, then these elements become part of the PA’s scope of practice and those medication prescriptions are ones he or she can initiate.

With a scope of practice established, our PA then functions under a single medical directive, which allows the PA to independently see patients whose issues fall within his or her determined competency. The PA still has a supervising physician assigned for each clinic, but for patient issues that are within the PA’s competencies the supervisor is only required to review the clinic notes. For issues outside the PA’s established scope of practice, the PA has to consult the supervising physician before the clinic visit is concluded. As the PA continues to see new patient problems and develop experience and knowledge, he or she uses the tracking forms to record the management of issues and use of medications that are outside his or her scope of practice. The PA’s scope of practice is reviewed on a regular basis and further enlarged as evidence of competency accumulates.