Follow this algorithm to determine if all or part of an APRN’s or PA’s practice is hospital facility-based for purposes of delegating prescriptive authority. If the APRN’s or PA’s clinical responsibilities include both ambulatory care and hospital settings, go through the algorithm separately for each aspect of the job in which the APRN or PA will be prescribing or ordering drugs or medical devices.
- Does the APRN or PA’s delegating physician meet the definition in 157.054, Occupations Code?http://www.statutes.legis.state.tx.us/Docs/OC/htm/OC.157.htm . In other words, the delegating physician is the Medical Director, Chief of Medical Staff, Credentialing Committee Chair, Department Chair, or a physician who consents to the request of the Medical Director or Chief of Medical Staff to delegate the prescribing or ordering of a drug or device in the same hospital at which the APRN or PA practices.
If the answer to question #1 is yes, then continue.
- Is the delegating physician solely delegating prescriptive authority using the facility-based designation at the hospital where the APRN or PA practices? In other words, the physician is not delegating under the facility-based designation at any other hospital or long-term care facility.
If the answer to question #2 is yes, continue.
- Does the APRN or PA spend his/her clinical time seeing inpatients in the hospital, hospital ER, or other hospital department? (This includes any outpatient departments on premises in the hospital that are operated by the hospital.)
If the answer to question #3 is yes, continue.
- Do the APRN or PA’s duties in the hospital include rounding on ALL patients for the service, or does the APRN/PA spend 100% of clinical time in the hospital seeing patients for the delegating physician or the delegating physician’s group? To clarify, if time is split between hospital and ambulatory care settings and the APRN or PA is only rounding on hospitalized patients that are patients in the ambulatory care setting, answer No to this question.
If the answer to all four questions are yes, the APRN/PA’s practice is facility-based.
Prescriptive Authority Delegation Document
If the APRN/PA’s practice is facility-based, a facility-based physician has the option, in accordance with facility medical staff bylaws and policies, of delegating prescriptive authority through a Facility-Based Protocol or a Prescriptive Authority Agreement (PAA). If any answer is “no”, then the APRN/PA’s practice is probably not facility-based (for at least a portion of the job) and the APRN/PA and delegating physician must develop a PAA. Whether facility-based or not, when delegating through a PAA, the parties to the agreement must meet all mandatory requirements related to PAAs (see TMB Rules 193.7 and 193.8).
In order for jobs that are split between outpatient and inpatient responsibilities to be 100% facility-based (and therefore, have prescriptive authority delegated only through a Facility-Based Protocol), the answers to the four questions must be “yes” for both portions of the job. Delegating physicians for APRNs/PAs who answer “yes” regarding the inpatient portion of their clinical duties, but “no” to one or more questions regarding the ambulatory care portion, have three options. The physician may delegate:
1) both the facility-based and non-facility-based aspects of the job using a PAA;
2) in the ambulatory care setting through a PAA and continue using a Protocol for the facility-based portion; or
3) in both locations through one a PAA that does not designate the hospital practice as facility-based.
Physicians using the third option would be limited to delegating to no more than seven APRN and/or PA FTEs and would only be permitted to delegate prescribing or ordering Schedule II Controlled Substances to hospice patients.)
Further Considerations for Delegating Physicians and Group Practices
- Physicians are limited to delegating at only one hospital or two long-term care facilities using a facility-based designation. (In addition, through a Prescriptive Authority Agreement, the physician may also delegate prescriptive authority at other locations, including additional hospitals, to a maximum of 7 APRNs and/or PAs, or their full-time equivalents, as long as the physician meets all the minimum requirements associated with executing a PAA.)
- Only facility-based physicians (i.e. physicians meeting the definition in 157.054, Occupations Code) may delegate prescribing or ordering Schedule II Controlled Substances to APRNs or PAs, and those APRNs and PAs must be practicing in the hospital’s ER and/or caring for in-patients with an intended length of stay of 24 hours or greater. (A physician does not have to be facility-based to delegate Schedule II drugs to an APRN or PA providing care for hospice patients.)
- Each APRN or PA working with physicians in a group practice or hospital department is only required to have one delegating physician, even when other physicians from the practice or facility supervise the APRN or PA on a rotating basis. If the APRN/PA is supervised by other physicians, those physicians should be identified in the Protocol and/or PAA as alternate physicians.
- Facility-based physicians in a hospital are not limited in the number of APRNs and PAs to whom the physician may delegate prescriptive authority in that hospital.
- Facility-based physicians delegating prescriptive authority through a Protocol are not required to register the delegation with the Texas Medical Board (TMB). However, any physician delegating through a PAA is required to register the delegation using the TMB’s online registration form (beginning January 2014).
- APRNs and PAs are not limited in the number of physicians who may delegate prescriptive authority to them. Therefore, as long as the physicians and APRNs/PAs otherwise meet the facility-based requirements, physician group practices with APRNs and PAs that cover more than one hospital may designate one physician at each hospital to delegate to all the group’s APRNs and PAs in that hospital under the facility-based provisions.