Chapter 28 - Physician Assistants

3-28.1  INTRODUCTION

1. Purpose.  The purpose of this chapter is to:
   1. Establish minimum Physician Assistant (PA) qualifications for employment in the Indian Health Service (IHS);
   2. outline PA certification, privileging, and training requirements for the IHS; and
   3. establish the IHS policy for national standards of practice for PAs
2. Background. A PA is a health professional who provides primary or specialty medical care in association with physicians and other members of the health care team. The IHS PAs are able to exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. 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 Physician Assistants (NCCPA) for all positions in the GS-0603 series.

3. Policy. It is IHS policy to employ PAs to expand health services and improve the quality of medical care provided to American Indians and Alaska Natives and to use physicians more effectively and efficiently. The IHS determines the scope of practice for PAs working for the IHS.

3-28.2  PROFESSIONAL CREDENTIALS

1. Education.  All PAs employed by the IHS must be graduates from one of the following:
   1. 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 its predecessors, at a college, university, or educational institution that is accredited by an accrediting body or organization recognized by the U.S. Department of Education at the time the degree was obtained; or
   2. An IHS intramural PA training program in operation between 1971-1983. Graduates from the IHS program may also be known as Community Health Medics (CHM).
2. Certification. All PAs are required, to possess at the time of employment current certification by the NCCPA and must maintain that certification throughout their employment with the IHS. The Office of Personnel Management’s (OPM) Qualification Standards for Physician Assistant, 0603 occupational series Exit Disclaimer: You Are Leaving www.ihs.gov , requires that all civilian PAs hired into a position after October 1, 2017, whether it be a new hire, re-hire, reassignment, transfer, or non-career ladder promotion, must hold a current NCCPA certification and licensure (OPM NOTE: civilian PAs currently assigned to positions in this occupational series as of September 2017 will be considered to have met the basic requirements for the position occupied). All PAs 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, once that certification expires. NCCPA certification is a condition of employment and an OPM requirement for all positions classified in the 0603 Physician Assistant occupational series. If a PA does not maintain NCCPA certification at all times, immediate administrative action should be initiated through contact/coordination with Human Resources. Administrative action taken may range from an Official Reprimand up to and including removal from Federal service. Exemptions to maintaining current certification (which are not applicable to USPHS PA officers) are as follows:
   1. All PAs and CHMs who were hired prior to October 1, 2017, 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.
   2. Recruitment of potential PA candidates is appropriate while individuals are completing the PA training program. Individuals may apply and be deemed tentatively qualified and tentatively selected for a PA position up to nine months before they graduate. However, they must graduate in good standing and obtain NCCPA national certification before they are officially offered a position.
3. 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 two (2) years in order to maintain NCCPA certification. Facilities are required to provide the time and necessary funding as appropriate to ensure all assigned PAs remain current in their clinical skills.
4. Hiring facilities. Hiring facilities are encouraged to provide cultural orientation during the new provider orientation process. This may consist of, but is not limited to: Official IHS cultural orientation educational material, shadowing Community Health Workers (Community Health Representatives, Public Health Nurses) during home visits (by invitation only), attending cultural celebrations or ceremonies (by invitation only) or touring the reservation. Cultural competence is a key to provider success, and providers are more likely to be retained when socially engaged in the community they serve.
5. Licensure. For all grade levels and positions, applicants must possess a current, active, full, and unrestricted license or registration as a PA from a State, the District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.
6. Other Requirements. In addition to the professional credentials identified in Sections A through E above, there are qualifications requirements established by the Office of Personnel Management for all grades within the PA Series 603. These additional requirements can be located at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/0600/physician-assistant-series-0603/ Exit Disclaimer: You Are Leaving www.ihs.gov .

   Additionally, employees currently assigned to positions in this series as of September 2017 (OPM published qualification standards changes) will be considered to have met the basic requirements for the position occupied.

3-28.3  RESPONSIBILITIES

1. Facility Clinical 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. The PA’s clinical privileges shall be commensurate with their education, experiences, competencies, and operational needs for the service to which they are assigned.
2. Physician Assistant.
   1. 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, and research. PAs are eligible to serve in administrative and supervisory positions as assigned by local, area or national authority.
   2. Collaborating with, Consulting and Referring to Physicians. PAs collaborate with, consult with and refer to physicians and other members of the health care team as indicated by the patient’s condition and the standards of care in accordance with the PA’s training, experience, and current competencies. A physician is not required to be present at the time and place where the PA provides medical services. PAs may practice at remote sites or after hours without a collaborating or consultative physician on-site as long as the PA is able to be in contact with a physician via telecommunication. As full members of the medical team PAs exercise autonomous medical decision-making and take full responsibility for the patient care they provide.
   3. Prescribing Privileges. The PA prescriptive authority for inpatient and outpatient pharmaceuticals will be established through individualized clinical privileging. Prescriptions or medication orders written by PAs within their privileges will not require a physician co-signature. Prescribing privileges may include the following:
      1. writing prescriptions;
      2. writing or establishing inpatient orders (if so privileged);
      3. dispensing medications (as required by clinical setting and facility policy and procedures);
      4. administering pharmaceuticals, where appropriate to do so; and
      5. procuring prescription drugs and devices from manufacturer and distributors.
   4. Prescribing Privileges for Drug Enforcement Administration (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:
      1. The facility has authorized the PA to dispense or prescribe designated schedules of controlled substances under its DEA registration or a personal DEA registration.
      2. The PA must be registered, licensed, or otherwise specifically recognized by a state authority in accordance with DEA requirements to prescribe designated schedules of controlled substances.
      3. The PA adheres to all local facility policies regarding the prescribing of controlled substances.

3-28.4  QUALITY MEASURES AND SCOPE OF PRACTICE

1. 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.
   1. The clinical competence of PAs will be reviewed and documented regularly and will include patient care review in accordance with local policies and procedures.
   2. In facilities where more than one type of clinician/practitioner is employed (Medical Doctor, Doctor of Osteopathic Medicine, Advanced Practice Registered Nurse), PAs may participate in the review and evaluation of their colleagues’ clinical performance as directed by their supervisor and as permitted by their local medical staff bylaws.
   3. The review of prescribing practices shall be employed for PAs in the same manner as for other members of the facility’s medical staff.
   4. Physician co-signature for PAs on medical records or prescriptions is not an IHS requirement but may be used for third-party billing purposes. In the absence of a PA team leader/supervisor, who would oversee the training and orientation of PAs in support of the PA care team, Physician co-signatures may also be utilized on an individual basis, e.g., during the initial appointment or if clinical privileges have been restricted or reduced.
2. 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:
   1. perform initial and/or periodic histories and physical examinations;
   2. provide and coordinate comprehensive care for patients in any assigned care setting and in accordance with training and education;
   3. manage acute, episodic, and chronic conditions and refer patients when disease process exceeds the PA’s education, training, and/or experience;
   4. screen patients to determine the need for further healthcare;
   5. 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;
   6. carry out patient-centered health promotion and disease prevention activities including education and shared decision-making;
   7. provide appropriate periodic mental health assessment, screening, counseling and treatment for mental illness, family violence, and diseases of addiction;
   8. draw blood or obtain other specimens for laboratory testing as needed;
   9. initiate and expedite requests for consultations and arrange special tests and studies;
   10. write orders as necessary for the care of the patient in accordance with this chapter;
   11. record progress notes and summaries in the patient’s medical record;
   12. obtain informed consent and document performed procedures;
   13. educate and counsel patients and families in preventive care, medical conditions, and the use of prescribed treatments and drugs;
   14. prescribe and dispense medications and durable medical devices and supplies;
   15. prescribe and dispense controlled substances within jurisdiction of the PA’s State license and facility policy;
   16. perform excisions, biopsies, incision and drainage, laceration repairs, castings, and additional procedures in accordance with training and clinical privileges;
   17. if specifically privileged to provide inpatient care, make daily rounds to observe and record patient’s medical progress; update and summarize medical records; initiate or change orders when appropriate; and notify the physicians of significant changes in a patient’s condition as indicated. Consultations with physicians should be documented. “Notes and Orders” do not routinely have to be cosigned. The PA may prepare the discharge summary, but the physician must write a discharge note or cosign the discharge summary if required by The Joint Commission or Centers for Medicare & Medicaid Services standards; and
   18. if specifically assigned to a surgical unit, perform duties of first assistant during surgical procedures. Provide preoperative, intraoperative, and postoperative care and procedural support in accordance with their training and experience, when specifically privileged by the facility and as directed by the attending surgeon in person or by protocol.
3. Emergency Duties/Conditions. The PA may manage the care of patients in life-threatening situations and makes every effort to safeguard, stabilize and treat the patient through the course of the medical emergency until relieved by a higher medical authority, or the transfer of the patient to a more appropriate medical service or facility. All PAs employed by the IHS system of hospitals and clinics are expected to obtain and maintain Basic Life Support certification. Additional certifications may also be required depending on the individual PA’s position description, and the resources and needs of the employing facility. Examples of emergency duties may include, but are not limited to the following:
   1. cardio pulmonary resuscitation;
   2. Advanced Cardiac Life Support and defibrillation;
   3. treatment of acute respiratory failure;
   4. treatment of life threatening traumatic injuries;
   5. identification, evaluation, and initiation of appropriate treatment to stabilize patients presenting with any life threatening or medically urgent injuries, illness, or conditions; and
   6. performance of all diagnostic and therapeutic emergency medical procedures for which he or she has been properly trained and privileged.