Advanced Concepts in Privileging AHPs. Wendy R. Crimp, BSN, MBA,CPHQ. Vicki L. Searcy, Vice President, Consulting Services Morrisey Associates

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1 Advanced Concepts in Privileging AHPs Presented at: CAMSS 42 nd Annual Education Forum San Diego, California May 29, 2013 Wendy R. Crimp, BSN, MBA,CPHQ Vicki L. Searcy, Vice President, Consulting Services Morrisey Associates What is the difference between traditional AHPs and Advanced Practice AHPs? Relevant CMS requirements Coordinating employment and privileging with Human Resources (for employed practitioners) Delineating privileges Linking standardized procedures and protocols to privileges Additional privileging issues

2 Are they specified professional personnel? mid-level providers? dependent practitioners? medical associates and/or assistants? An Advanced Practice AHP would typically NOT include the following: Physician employed scrub techs Physician employed dental assistants Physician employed RNs Don t use this term: Independent AHP if the services provided by the AHP are subject to some type of supervision Determining What Healthcare Professionals Must be Credentialed and/or Privileged Don t make a decision» Based on how a healthcare professional enters the organization Do consider» What services the category of healthcare professional will provide (medical level of care?)

3 Practitioners who provide a medical level of care must be credentialed and privileged through the Medical Staff process. Generally applicable to physician assistants and advanced practice registered nurses, but can also include other types of advanced practice AHPs (for example, RN First Assistants). What does medical level of care mean??? Term is not defined by CMS Care provided for which CMS pays physicians Services traditionally provided by physicians Defined by state medical board The governing body must: (a)(1) Determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff; Practitioners, both physicians and non-physicians, may be granted privileges to practice at the hospital by the governing body for practice activities authorized within their State scope of practice without being appointed a member of the medical staff (a)(4) If the hospital utilizes RN First Assistants, surgical PAs, or other non- MD/DO surgical assistants, the hospital must establish criteria, qualifications and a credentialing process to grant specific privileges to individual practitioners based on each individual practitioner s compliance with the privileging/credentialing criteria and in accordance with Federal and State laws and regulations. This would include surgical services tasks conducted by these practitioners while under the supervision of an MD/DO. When practitioners whose scope of practice for conducting surgical procedures requires the direct supervision of an MD/DO surgeon, the term supervision would mean the supervising MD/DO surgeon is present in the same room, working with the same patient.

4 CMS Definition of Surgery (from Medicare Conditions of Participation for Hospitals Interpretive Guidelines): Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reductions for major dislocations or fractures, or otherwise altered by mechanical, thermal, light-based, electromagnetic, or chemical means. Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system also is considered to be surgery (this does not include the administration by nursing personnel of some injections, subcutaneous, intramuscular, and intravenous, when ordered by a physician). All of these surgical procedures are invasive, including those that are performed with lasers, and the risks of any surgical procedure are not eliminated by using a light knife or laser in place of a metal knife, or scalpel. Patient safety and quality of care are paramount and, therefore, patients should be assured that individuals who perform these types of surgery are licensed physicians (physicians as defined in (c)(1)) who are working within their scope of practice, hospital privileges, and who meet appropriate professional standards. If a surgical assistant s or RNFA s duties are limited to holding retractors or instruments as directed by the surgeon, applying electrocautery at direction of the surgeon, passing instruments, sponging, suction, and other non-invasive tasks performed at the direction of and under supervision of the surgeon, these tasks do not meet the definition of performing surgery and the practitioner would not need to be granted privileges. However, if the assistant will be suturing or cutting tissue (even if done under direction by and under supervision of the surgeon) this would be structurally altering the human body by the incision or destruction of tissues, meaning it meets the definition of surgery and would thus require privileges to be granted. Source: David W. Eddinger, RN, MPH Technical Director Hospital Survey and Certification CMS/CMSC/Survey & Certification Group/Division of Acute Care Types of Supervision General Supervision means the procedure is furnished under the physician s overall direction and control, but the physician s presence is not required during the performance of the procedure or provision of the services. Direct Supervision means the physician must be present in the office suite or on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. Personal Supervision means a physician must be in the room during the performance of the procedure.

5 Joint Commission Requirements Those who provide medical level of care must use the medical staff process for credentialing and privileging, making all MS standards applicable (including recommendation by the organized medical staff and approval by the governing body, OPPE, and FPPE). APRNs should request privileges only for those responsibilities involving medical level of care and not those responsibilities already allowed under the RN scope of practice APRNs and PAs who provide medical level of care must be credentialed and privileged through the Medical Staff standards process APRNs and PAs who do not provide medical level of care can utilize the human resources equivalent process HR , EPs Source: Standards Booster Pak for FPPE/OPPE Jan/2011

6 CMS» AHPs that provide a medical level of care Usually includes PAs and APRNs» RNFAs»??? Method for Privileging» Medical Staff process Joint Commission» Any AHP that functions as an LIP» PAs (must provide a medical level of care)» APRNs (must provide a medical level of care)» Other non-lips who provide a medical level of care Method(s)» Medical staff privileging process» There is no equivalent process for practitioners who provide a medical level of care Development of Privileges

7 Find out what they do (currently) or what services the organization wants to let them provide (major voyage of discovery!) The decision about what Advanced Practice AHPs will be allowed to do in the hospital setting must not be solely decided by physicians due to anti-trust issues Research community standards For APRNs - Differentiate between nursing services provided (those services that may be provided by an RN) vs. those services that are comparable with services provided by physicians ( medical acts as required by CMS) Important! Just because an Advanced Practice AHP is licensed by the State to provide a service doesn t mean that an organization is required to allow the AHP to provide that service. However, there is some evolving case law in some States that is worth keeping an eye on. Remember that physicians are routinely licensed to practice medicine and surgery it is the hospital that determines specifically what services a physician will be permitted to provide within the hospital based upon Services the hospital provides Established qualifications/criteria based on licensure, education, training, health, current competency, etc. The California Medical Practice Act authorizes physicians to diagnose mental and physical conditions, to use drugs in or upon human beings, to sever or penetrate the tissue of human beings and to use other methods in the treatment of diseases, injuries, deformities or other physical or mental conditions. Whenever a specific duty, task or activity exceeds the scope of nursing practice as defined by the Nursing Practice Act or Board of Registered Nursing.

8 Legal Authority for Practice The NP does not have an additional scope of practice beyond the usual RN scope and must rely on standardized procedures for authorization to perform overlapping medical functions (CCR Section 1485). (Similar constraints apply to CNM and CNS.) NPs and CNMs must have a separate furnishing permit in addition to DEA PA s do not have the same constraints as APRNs The scope of a given PA's practice is limited by his/her supervising physician. Whatever medical specialty a physician practices (e.g., general practice, cardio-thoracic surgery, dermatology, etc.) limits the scope of practice. The Delegation of Services Agreement between the PA and the supervising physician then further defines exactly what tasks and procedures are being delegated to the PA. These tasks and procedures must be consistent with the supervising physician's specialty or usual and customary practice and with the patient's health and condition. Before authorizing a PA to perform any medical procedure, the physician is responsible for evaluating the PA s education, experience, knowledge, and ability to perform the procedure safely and competently. PA s are not required to have a separate furnishing certificate for prescribing just a DEA. Therapeutic Prescribing Authority Certificate Authorizes the optometrist to perform various diagnoses and therapies typically reserved for ophthalmologists. An organization may elect to privilege optometrists who have TPA Certificates depending upon what the optometrist is allowed to do at the organization.

9 The delineation of privileges for an Advanced Practice AHP (PAs and APRNs) or any healthcare professional granted clinical privileges must be the source of information for clinical services the Advanced Practice AHP can provide Job descriptions for employed Advanced Practice AHPs should point to the privilege delineation The permission to function under standardized procedures or protocols (if present) should be linked to granted privileges Privilege delineations trump standardized care arrangements or collaborative agreements If someone needs to find out what an Advanced Practice AHP can do, they shouldn t have to look at multiple documents If we want to find out what a radiologist can do, we look at his/her privilege delineation form not his/her contract or his/her job description We look at the contract to develop the privilege delineation form APRNS Start with the California Board of Nursing Website APRNs include: CNS (Clinical Nurse Specialist) CNM (Certified Nurse Midwife) CRNA (Certified Registered Nurse Anesthetist) NP (Nurse Practitioner)

10 Where to Find Information for Development of Privileges for PAs What are the qualifications to become licensed as a physician assistant in California? Complete an approved physician assistant training program. See the list of approved physician assistant training programs. Take and pass the Physician Assistant National Certifying Examination (PANCE) administered by the National Commission on Certification of Physician Assistants (NCCPA). Information on the PANCE is available on the NCCPA's Web site at Either a multi-specialty style can be used or a specialty-specific delineation can be used. It will depend upon the variety of specialties found in your organization and other factors. The multi-specialty privilege form (see sample) The specialty-specific privilege form (see sample) In Summary Perform Research: Find out what services Advanced Practice AHPs are licensed to provide (and any requirements related to provision of those services, such as collaborative agreements, specific identification of supervising physician, standard care arrangements, etc.) What qualifications Advanced Practice AHPs must meet in order to provide services from a statutory perspective Qualifications that Advanced Practice AHPs must meet in order to be certified Find out (when possible) what services Advanced Practice AHPs are qualified/competent to provide because of a specific certification

11 Determine your organizations intent related to Advanced Practice AHPs practice What is the scope of services that your organization wants to allow each category of Advanced Practice AHPs to provide Make sure that the privilege delineation form is the authoritative source for the services Advanced Practice AHPs are permitted to provide Use essentially same privileging format for Advanced Practice AHPs that is used for LIPs (i.e., don t use a laundry list for AP AHPS if you use core privileges for LIPs Remember that privileges must be criteria-based Many Advanced Practice AHPs provide services only in the outpatient setting. We often find that privileges have not been delineated in these areas. Privileges must be delineated in all areas that are subject to the accreditation process However, privileges do not have to be site specific unless an AP AHP is only permitted to provide services in a specific site (for example, if an NP is permitted to perform an HP, the organization does not need to specify where the HP may be performed) Same process that is used for LIPs applies to Advanced Practice AHPs Joint Commission credentialing and privileging standards are applicable Data collected via application form (education, training, history, etc.) What is verified/how should be the same (as applicable) as what is verified for LIPs Peer references Evaluation and decision-making route often varies by the addition of the Interdisciplinary Practice Committee layer

12 Coordinating Employment and Privileging Many Advanced Practice AHPs are employed by the healthcare organization that must also privilege them Employment and credentialing/privileging processes must be coordinated Privileges cannot be exercised until they have been granted Standards related to temporary privileges are applicable to Advanced Practice AHPs - Pending application or urgent patient care/service need HR File» Employment application» Information related to salary, payroll deductions, etc.» Job description (recommend that clinical responsibilities be described in the privileging document) Credentials File» Application» Delineation of privileges» Verifications as required for LIPs, including peer references, NPDB report, licensure verification, etc.» Evaluation(s) of competency

13 Remember that credentialing and privileging of AHPs is a work in process. We can be certain that CMS will continue to refine the requirements related to these issues. In the meantime, we should: Apply common sense and be ready to defend our decisions Remember that protecting patients is a primary goal of what we should do We should also protect the reputation of our organizations Q&A

14 Wendy R. Crimp, BSN, MBA, CPHQ Director The Crimp Resource Group Wendy R. Crimp provides senior-level management consulting for Morrisey Associates, Inc. During her more than 25 years of experience in the healthcare industry, Ms. Crimp has specialized in operations cost management and service delivery in a variety of healthcare organizations and medical groups. She has held executive and middle management positions and has proven consulting expertise in both for-profit and non-profit provider environments. Her extensive operational and project management experience provides an excellent framework for understanding organizational requirements needed to achieve successful management outcomes. Ms. Crimp has provided consulting services to hospitals, health systems, municipal public health agencies, medical groups, and universities. Her services have included: development and implementation of both operational quality and clinical quality management programs; management of organizations in transition; interim and long term operations planning; organizational restructure; productivity and operations bench marking; workflow redesign and optimizing the use of technology. Her clinical, financial and management engineering background assists in successfully bridging the agendas of various organizational stakeholders. Her emphasis is on transitioning clients from planning for change to actual implementation, thus, she is an effective project manager/implementer in complex organizational environments. Ms. Crimp is a content expert in the area of clinical quality management, credentialing and privileging and peer review. Ms. Crimp has authored numerous articles published in a variety of trade journals such as Synergy, Modern Healthcare and the AHA Journal and is a contributing author to Handbook of Medical and Professional Staff Services Management by Aspen and Core Privileges for Physicians by HCPro, Inc. She is a regular speaker at national and state conferences. Ms. Crimp received a Masters in Business Administration from the University of California at Irvine and a Bachelor of Science degree, with distinction, in Nursing from California State University of Long Beach, California. She has an active Registered Nursing License and is Certified in Public Health in the State of California. She is also a Certified Professional in Healthcare Quality (CPHQ).

15 Vicki L. Searcy Vicki L. Searcy is the Vice President, Consulting Services at Morrisey Associates, a Chicagobased company. In addition to oversight of all consulting services, she provides healthcare consulting services specializing in practitioner competency management, including credentialing, privileging, privileging of advanced practice professionals, quality and peer review as well as management issues related to medical staff organizations. Prior to joining Morrisey Associates, Inc., she served as the Practice Director, Credentialing & Privileging for The Greeley Company and as President of Searcy Resource Group, LLC. Ms. Searcy s career also includes being a partner with BDO Seidman, LLP, one of the nation s leading accounting, tax, and consulting firms, heading up their national healthcare accreditation and compliance consulting practice. For over ten years, Ms. Searcy was a surveyor for the National Committee on Quality Assurance for their CVO certification program. She is a past-chair of the of the Certification Council of the National Association Medical Staff Services (NAMSS) as well as a past-president of NAMSS. Ms. Searcy provides consulting services to a variety of healthcare organizations, including hospitals, healthcare systems, health plans, medical groups and credentials verification organizations. Ms. Searcy is often involved in projects where changes in operations are necessary in order to meet accreditation/licensing standards as well as to improve productivity and operational efficiency. She has been instrumental in working with organizations achieve paperless/electronic credentialing. She also provides retreats and other education programs for physician leaders and governing body members. During her work in hospitals and health systems, Ms. Searcy had responsibility for program design and implementation in the following areas: Utilization/Case Management, Medical Records, Medical Staff Services, Quality Management, Risk Management, and Outpatient Services. Ms. Searcy has served as seminar faculty for several national educational providers and professional organizations, including the national seminars of The Greeley Company (Advanced Credentialing & Privileging Retreat, Credentialing Resource Center Symposium, Core Privileges Essentials), the American Society for Healthcare Risk Management, National Association Medical Staff Services, National Association for Healthcare Quality, the American

16 Medical Group Association, American Health Information Management Association and the American Hospital Association. Ms. Searcy was the founding editor for Health Care Competency & Credentialing Report. She has written numerous articles related to issues in medical staff organization management which have been published in a variety of newsletters and magazines. Books include: Core Privileges for AHPs: A Practical Approach to Developing and Implementing Criteria-Based Privileges (to be published in 2008 by HCPro, Inc.) Co-authors: Carol Cairns and Sally Pelletier Core Privileges for Physicians: A Practical Approach to Developing and Implementing Criteria-Based Privileges (published in 2007 by HcPro, Inc.) Co-authors: Wendy R. Crimp, Sally Pelletier and Mark A. Smith, M.D. Measuring Physician Competency: How to Collect, Assess and Provide Performance Data (published by HCPro, Inc. 2007) Co-authors: Robert Marder, M.D. and Mark A. Smith, M.D. Credentialing Audits: Tools for Compliance and Reduced Liability (published in 2006 by HCPro, Inc) The Medical Staff Services Handbook: Fundamentals and Beyond (published by Jones and Bartlett in 2010). Co-authors are Cindy Gassiot and Christine Giles. See website: Professional Excellence = Professional Advancement 101 Smart Things Every Medical Staff Services Professional Should Do (published in 2005 by Searcy Resource Group, LLC and distributed by NAMSS). Co-author is Peggy A. Greeley. Ms. Searcy is a recipient of the Woman of Achievement Award in Healthcare from the City of Los Angeles.