Risk Management – Considerations for Physical Therapy Service Delegation to a PTA
Physical therapy (PT) is an important medical field that focuses on restoring and promoting functional ability and morbidity. In addition to rehabilitation after loss of morbidity, PT practitioners are responsible for preventing loss of morbidity through the promotion of healthier lifestyles and fitness programs (APTA, 2013).
According to Gardner (2013), the practice is carried out largely by physical therapists (PT) and physical therapist assistants (PTA). PTs are licensed to conduct examinations, diagnose and offer treatments for disabilities, impairments and functional limitations. Most PTs have master’s level education and can work autonomously or in multidisciplinary health care delivery teams
PTAs on the other hand have 2 year associate degrees and work under the supervision of the PT. There are various services that a PT can delegate to the PTA working under him. Delegation is performed in order to improve the quality of care offered (Needham and Radha278). However, there are inherent risks that come with delegating PT services to a PTA. This paper seeks to establish that the PT delegates duties to the PTA with the aim of enhancing quality of care.
Understanding the duties of a PT and those of a PTA is important in determining the risks involved with delegation of duties. A PT can independently consult with patients in which case a screening exercise is conducted to determine the patient’s needs and if the patient might need referral to other health care professionals. After screening, the PT conducts an examination, and diagnosis using measurement instruments and by requesting relevant laboratory examinations (Stevens, Anita and Beurskens 954) PTAs on the other hand work under the supervision of PTs to implement the formulated health care plan and evaluate patient progression. A PT must consider the appropriateness of the delegation in terms of quality of care and patient satisfaction in determining whether to delegate a duty.
The risk is deciding which duties to delegate that are clinically sound and will result in better patient outcomes. For instance, where language barrier exists between the patient and the PT, the PT may delegate more duties to the PTA if there are no language barriers between the patient and the PTA. Such a delegation will improve the quality of care offered and promote patient wellbeing. Determining which duties are clinically appropriate to delegate to a PTA is an important skill that competent PTs must develop. The American Physical Therapy Association (APTA) has robust guidelines that help to make decisions on what duties a PT should delegate to a PTA. According to these guidelines, some duties such as screening, examination, diagnosis, formulation of health care plan, prognosis and documentation can only be done by the PT (Swisher and Peggy 818).
The first one is following the APTA guidelines on which duties to delegate. The most important should be avoiding delegating duties in which the PTA may be required to make clinical decisions. PTs should not have a one-size-fits-all policy on which duties to delegate. Instead, a PT should consider each case separately based on the training, skill level and experience of the PTA and the complexity and needs of the patient. Jette and Dianne (2012) assert that the skill level of a PTA determines the capability of the PTA in recognizing quality indicators in the implementation of a health care plan (516). PTAs with higher qualification, experience and skills can handle more delegated duties effectively.
In the delivery of care, an error can lead to liability claims by the patient. Determining who will bear the legal responsibility of a liability claim is the first step in a Suit. Should it be the PTA who was delivering care of the PT who was supervising the PTA? When a PT delegates duties to PTAs working under him/her, s/he remains professionally responsible for the delivery of care. The concept of professional liability is recognized in courts and PTs can be sued for the actions of PTAs working under them (Kachalia and Mitchelle1565). Therefore, PTs must make delegation decisions that they can defend, and are agreeable to most people. The risk of professional liability claims is significant but the PT can mitigate it
The basic strategy in mitigating professional liability claims is ensuring that duties are delegated to someone who has the necessary training, skills and experience to perform them. To reduce professional liability, the APTA guidelines stipulate that all delegation decisions should be consistent with what any other reasonable PT can do in similar circumstances. In addition, PTs must provide adequate guidance and supervision to PTAs working under them. The PT should be ready to take professional responsibility for decisions and actions made by the PTAs working under him which may adversely affect the patient. (Praestegaard et al, 2013)
Once the PT has determined a service that can be delegated to the PTA and promote patient well-being and the quality of care offered, it is important to determine if the service can be legally delegated.
The practice of physiotherapy is regulated by laws which determine what service each clinical member can perform and the level of supervision required from direct supervision to general and onsite supervision. In addition to State and Federal laws, health facilities have internal regulations. All PTs must be aware and comply with these regulations when delegating duties. Besides the legal requirements, there are ethical requirements that a PT must meet such as maintaining patient privacy (Delany et al. 1068). Ethical requirements are set out in the professional code of conduct. Physical therapists face ethical dilemma such as equality and the need to be in close physical and emotional contact with the patient (Praestegaars and Gunvor 96). There is a risk of delegating duties that may increase the discomfort of the patient because of being attended to by more than one therapist. While ethical violations may not always lead to legal violations and legal punishments, ethical violations often lead to exclusion from professional bodies.
The PT must consider the risks involved when delegating duties to a PTA in order to determine whether the duties violate any legal or ethical requirement. The penalties for violation of legal requirements are specified in the Physical Therapy Practice act in a given state. The actions usually include monetary fines and suspensions but revocation of the practice license is used in severe cases. Ethical violations can also attract fines and reduce the quality of care offered. To mitigate the risk of legal violation, it is important for PTs to be familiar with the State’s physical therapy practice act. In addition, PTs must realize that not all services that are permitted under the act for delegation to a PTA are appropriate at all times. “Keeping a copy of Federal, State and hospital regulation at hand is important so as to help make legally correct decisions. Besides that, PTs should practice social justice and professionalism and employ ethical decision making models to ensure that the delegation decisions made are agreeable to the patient and to other stake holders (Edwards et al. 1642)”.
Physical therapy services are medical services and are funded through the health care system. Because of the long-term nature of most physical therapy care plans, most patients pay for the services through health insurance or Medicare. Medicare dictates the reimbursement requirements, qualification of care providers, and the required supervision (Fehring). PTs must be aware of the reimbursement requirement of Medicare and insurance companies, which pay for physical therapy services for their clients. This is because Medicare and insurance companies pay only for the services that were delegated, and conducted in a manner that met regulatory requirements. Therefore, the PT and PTA must take this into consideration in order to avoid non-payment of fees for duties that were not properly (legally and ethically) delegated.
There is a risk of non-compliance to these regulations when duties are delegated to unqualified personnel or when no proper supervision is done. For instance, Medicare reimbursement requirements for PTs discourage delegating any duties to a physical therapy aide. Noncompliance can attract heavy refunds when the Medicare Recovery Audit Contractor Program determines incorrect payments and a PT risks exclusion from future Medicare reimbursements. To minimize the risk, PTs should be trained on the Medicare reimbursement requirements in terms of what duties can be delegated, the qualifications of the PTA to whom the duties are delegated and the manner in which the delegation and supervision are carried out.
Physical therapy is an important medical field that aims at maintaining or restoring morbidity after traumatizing events. The services are delivered by PTs who generally have masters or doctoral level education and PTAs who have associate degrees. Since the PTAs work under the PTs, there is a need to ensure proper delegation of duties between the PT and the PTA. The factors to consider when deciding which duty to delegate vary from case to case. There are risks that come with delegation of duties. For instance the professional liability remains with the PT when PT delegate’s duties to a PTA. Therefore the PTs must identify and minimize the risks associated with delegation of duties to the PTAs. To do this, PTs must consider which duties can be delegated legally and in keeping with the requirements of Medicare. Complying with Federal, State and hospital regulations ensure that delegation is conducted efficiently since these regulations are clear on which services can be delegated. In addition, PTs must provide sufficient supervision and guidance in consideration of the needs of the patient and the qualification of the PTA in terms of education skills and experience. PTs should act in the best interest of the patient and maintain professionalism by observing the code of conduct. When delegation is handled properly, the inherent risks are reduced and the overall quality of care offered in a facility increases.
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APTA . “Role of a Physical Therapist”. American Physical Therapy Association. Retrieved on 30th October, 2013 from <http://www.apta.org/PTCareers/RoleofaPT/> March 2013
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