Implicit delegation of authority occurs when the physician allows NPPs to act on their own initiative, by carrying out medical tasks without strict protocols. This is not a problem if these personnel are under the direct supervision of the physician, as a nonphysician surgical assistant is. Physicians are legally responsible for the actions of these personnel, but they also can recognize and correct any improper actions.

Problems arise in two situations: when NPPs initiate care outside the physician’s direct supervision and when the physician allows these personnel to perform tasks that the physician is not competent to perform. The physician remains legally responsible but can no longer prevent improper actions. The classic example of this type of implicit delegation of authority was the medical equipment sales representative showing the surgeon how to place a hip prosthesis. The salesman scrubbed and participated in the operation, to the point of placing the prosthesis. There was much consternation about a sales representative in the operating room, but this was no more legally significant than the use of a nonlicensed surgical assistant. The physician could not supervise the sales representative’s actions because the physician did not know how to do the procedure. Despite the proximity of the physician, knowledgeable supervision was impossible. (This action might also violate hospital rules on who is permitted in the operating room.)