Acupuncture. Background. Procedure 75

Transcription

1 Procedure 75 Clinical PRIVILEGE WHITE PAPER Background Acupuncture Acupuncture is one of the oldest medical practices in the world, originating in traditional Chinese medicine, and is most commonly used to treat chronic pain, according to the National Center for Complementary and Alternative Medicine (NCCAM). This technique involves the insertion of extremely thin needles through the skin and into strategic points on the body. Traditional Chinese medicine believes that acupuncture rebalances the flow of energy (called chi) in your body along pathways referred to as meridians. Western medicine sees these acupuncture points as ways to stimulate nerves, muscles, and connective tissue, which promotes activity of the body s natural painkillers. Acupuncture can be used by itself or as a complementary option to a treatment plan. Studies have shown that acupuncture has promising results when used to treat simple conditions including nausea, headaches, tennis elbow, and carpal tunnel syndrome, as well as lower back pain, fibromyalgia, asthma, and drug addiction. The FDA regulates acupuncture needles, requiring that they are sterile, nontoxic, labeled for single use, and used by qualified practitioners. Most states require practitioners to acquire a license to practice acupuncture, but requirements vary from state to state. There are very few risks associated with acupuncture, although there have been some complications from inadequate sterilization of needles. When needles aren t delivered properly, they can cause infection or punctured organs. Acupuncture has grown in popularity in the United States over the last decade. Between 2002 and 2007, acupuncture use among adults increased by about one million people, according to NCCAM. Acupuncturists, as well as conventional providers such as physicians and dentists, practice this treatment method. According to the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM), 23 states require acupuncture certification as of The American Association of Acupuncture and Oriental Medicine (AAAOM) notes that acupuncture has been reclassified in a number of ways to include trigger-point dry needling (TDN) and intramuscular manual therapy (IMT), but those techniques still fall under the auspices of acupuncture and require the same standards of training and education. A supplement to Credentialing Resource Center Journal /12

2 For more information on the specialties and subspecialties that may incorporate acupuncture, please see the following Clinical Privilege White Papers: Practice area 108 Pain medicine Practice area 125 Anesthesiology Practice area 134 Family medicine Practice area 145 Neurology Practice area 149 Orthopedic surgery Practice area 156 Physical medicine and rehabilitation Involved specialties Certified acupuncturists, family practitioners, anesthesiologists, neurologists, physiatrists, orthopedic surgeons Positions of specialty boards ABMA The American Board of Medical Acupuncture (ABMA) was established in April 2000 as an independent entity within the American Academy of Medical Acupuncture (AAMA) in order to promote safe and effective medical acupuncture with professional certification. In order to be certified through ABMA, candidates must graduate from an accredited allopathic or osteopathic medical school, possess a current, valid medical license, and have moral and ethical standing with the board. Candidates also need to complete the following training and education requirements: A minimum of 300 hours of systematic acupuncture education subsequent to graduation from medical school, which includes at least 200 hours in a program that meets World Federation of Acupuncture and Moxibustion Societies (WFAS) standards At least 100 of those 300 hours of education should be in clinical training If a candidate has received training in a program that has not been approved by the ABMA, the board must review the program and may administer an oral interview of the applicant if necessary Applicants must also submit an affidavit attesting that they have a minimum of two years of medical acupuncture clinical experience subsequent to the basic 300 hours of medical acupuncture training and an acupuncture case history of at least 500 medical acupuncture procedures. This should include experience in more than one area of acupuncture, including but not limited to energetic acupuncture, neuroanatomic acupuncture, five elements, traditional Chinese medicine (TCM), auricular, scalp, and hand. The ABMA is not a member of the American Board of Medical Specialties. 2 A supplement to Credentialing Resource Center Journal /12

3 ABA The American Board of Anesthesiology (ABA) certifies physicians in anesthesiology with a subspecialty in pain medicine. However, ABA does not include specific requirements for acupuncture. AOBA The American Osteopathic Board of Anesthesiology (AOBA) certifies physicians in anesthesiology, and also offers a certificate of added qualifications for pain management. AOBA does not include specific requirements for acupuncture. ABPMR The American Board of Physical Medicine and Rehabilitation (ABPMR) certifies physicians in physical medicine and rehabilitation and offers a certificate of added qualifications in pain management. However, ABPMR does not include specific requirements for acupuncture. AOBPMR The American Osteopathic Board of Physical Medicine and Rehabilitation (AOBPMR) certifies physicians in physical medicine and rehabilitation and offers a certificate of added qualifications in pain management. However, AOBPMR does not include specific requirements for acupuncture. ABPN The American Board of Psychiatry and Neurology (ABPN) certifies physicians in neurology and the subspecialty of pain medicine. However, ABPN does not list specific requirements for acupuncture. AOBPN The American Osteopathic Board of Psychiatry and Neurology (AOBPN) certifies physicians in neurology but does not list specific requirements for acupuncture. Positions of societies, academies, colleges, and associations NCCAOM The NCCAOM publishes requirements for certification in acupuncture. Applicants must pass examinations in the foundations of oriental medicine, acupuncture with point location, and biomedicine, and also provide proof of completion of the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) Clean Needle Technique course. A supplement to Credentialing Resource Center Journal /12 3

4 NCCAOM publishes four eligibility routes: Route 1 is formal education through a program accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). This pathway is open to U.S. residents only and requires 1,490 hours of training before a candidate is allowed to sit for the exam. Route 2 is formal education for international applicants. Applicants that use this pathway must graduate from an academic institution with approval by a foreign government s education or health ministry, and have approval by a foreign private accreditation agency with standards equivalent to the ACAOM. International candidates must also meet the same number of hours and distribution of hours as designated by the ACAOM. Those who do not meet those hours can take supplemental education at an ACAOM-accredited institution. Route 3 is apprenticeship. This includes training completed under a preceptor that provides practical and theoretical education. A maximum of two apprentices can study under one preceptor, and an apprentice can only study under one preceptor. Applicants that apply through this pathway must meet the following requirements: Have a minimum of 4,000 contact hours (direct supervision with the preceptor) with no less than three years and no more than six years of acupuncture training Adopt increasing responsibilities under the apprenticeship program Have a government or state license Alternately, applicants applying through the apprenticeship route may meet the following requirements: Practice a minimum of 500 acupuncture visits with more than 100 different patients for five consecutive years immediately after entering the preceptor program. The preceptor practice must maintain a minimum of 500 patient visits with no fewer than 100 different patients during each year. Smoking withdrawal and addictions may be included but will not count toward the 500 patient visits. Required documentation for the apprenticeship includes: A notarized letter from the preceptor that includes a detailed description of the apprenticeship, total contact hours, and the amount of time spent with theoretical and practical instruction, as well as a description of the preceptor s practice, including the number of patient visits each year A statement on the number of apprentices being supervised by the preceptor Documentation of the preceptor s practice, which must be a minimum of five years Notarized affidavits from two healthcare professionals that include testimony about the preceptor s practice Sample of applicant s notes Proof of completion of the Clean Needle Technique course 4 A supplement to Credentialing Resource Center Journal /12

5 Route 4 is a combination of formal education and apprenticeship. Applicants using this route are awarded points for both formal education and apprenticeship programs, to meet a maximum of 40 points, with no more than 30 points in one category. Ten points are awarded for each year of formal acupuncture education, which is defined as 450 hours. Ten points are awarded per 1,000 contact hours with a preceptor. A maximum of 10 points may be earned for each period of 12 consecutive months. All apprenticeship hours need to meet the criteria described under the apprenticeship route. ACAOM The Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) is a nonprofit organization founded by the CCAOM and the American Association of Oriental Medicine that accredits acupuncture and Oriental medicine programs using specific program requirements. In 2009 the ACAOM published its Accreditation Manual, which includes eligibility requirements and standards for acupuncture programs. According to ACAOM, the minimum length of a professional acupuncture curriculum must be at least three academic years composed of the following: 47 semester credits in Oriental medical theory, diagnosis, and treatment techniques in acupuncture 22 semester credits in clinical training 30 semester credits in biomedical clinical sciences Six semester credits in counseling, communications, ethics, and practice management The minimum length of a professional Oriental medicine curriculum must be at least four academic years and include the following: 47 semester credits in Oriental medical theory, diagnosis, and treatment techniques in acupuncture 30 semester credits in didactic Oriental herbal studies 29 semester credits in integrated acupuncture and herbal clinical training 34 semester credits in biomedical clinical sciences Six semester credits in counseling, communications, ethics, and practice management A professional acupuncture program must require at least 90 instructional weeks over the span of no fewer than 27 calendar months, whereas a professional Oriental medicine program must be at least 120 instructional weeks over 36 calendar months. Additionally, students in an acupuncture program must participate in at least 500 hours of supervised patient care, while students in Oriental medicine must participate in at least 700 hours. This must consist of at least 250 intern-performed treatments in the acupuncture program and 350 in the Oriental medicine program. A supplement to Credentialing Resource Center Journal /12 5

6 WHO/WFAS The World Health Organization (WHO) and the WFAS published Guidelines on Basic Training and Safety in Acupuncture in 1999, which remain in effect to this day. The guidelines break down training requirements for acupuncture practitioners, as well as full and limited training for qualified practitioners. Regarding acupuncture practitioners, students must have two years of fulltime training with a minimum of 2,500 hours, with no less than 1,000 hours of clinical work. Part of that training should include the core syllabus of acupuncture, which includes: A brief history of acupuncture Basic theory Knowledge of acupuncture points Diagnosis Treatment in accordance with national laws and regulations, including: Principles of treatment Guidelines on safety in acupuncture Treatment techniques Treatment of disease, illness, and conditions that are commonly associated with acupuncture Acupuncture treatment emergencies Prevention in traditional medicine This program should also include training in modern Western medicine, including the essentials of anatomy, hygiene, patient examinations, first aid, cardiopulmonary resuscitation, and the action to take in emergency situations. The pathway of full training in acupuncture for qualified physicians is designed for physicians who already have training in modern Western medicine and wish to practice acupuncture independently. Qualified physicians would only need to follow the core syllabus for acupuncture with at least 1,500 hours of formal training, including 1,000 hours of practical and clinical work. With regard to limited training for qualified practitioners, some physicians may only need a shorter training course to become competent in acupuncture. The course for this pathway should be 200 hours of formal training and include: Introduction to traditional Chinese acupuncture Acupuncture points Applications of acupuncture in modern Western medicine Safety guidelines Treatment techniques 6 A supplement to Credentialing Resource Center Journal /12

7 In some cases physicians may wish to specialize in specific areas of acupuncture such as pain relief or dental, which would require more flexibility in designing a special curriculum to their area of interest. Additionally, physicians that complete the shorter course should also consider pursuing advanced-level training. AAMA The AAMA publishes the Criteria for Hospital Privileges in Medical Acupuncture, which include qualifications and training along with peer review and quality assurance plans. According to the AAMA criteria, qualified physicians must have the following: State license 200 hours of graduate training in medical acupuncture at AMA category one certified programs, approved by the hospital s medical acupuncture committee or through an endorsement of the AAMA Three letters of recommendation attesting to the applicant s qualifications Evidence of at least 30 accredited hours of continuing education over a three-year period Board certification in medical acupuncture within three years of being granted privileges All physicians should also be evaluated through the quality assurance program of the physician s specialty department. In the event of a negative outcome, the case should be evaluated through peer review by a special hospital committee. Physicians using medical acupuncture should still establish diagnoses within traditional Western medicine, and the rationale for using acupuncture should be documented. AAAOM The American Association of Acupuncture and Oriental Medicine (AAAOM) indicates in its professional standards that it supports ACAOM s professional standards for academic standards and professional competencies. AAAOM also published a 2011 position paper entitled American Association of Acupuncture and Oriental Medicine (AAAOM) Position Statement on Trigger Point Dry Needling (TDN) and Intramuscular Manual Therapy (IMT). In this statement, the AAAOM indicates that it endorses the educational requirement set forth by the ACAOM and the certification standards set forth by the NCCAOM. However, AAAOM writes that there has recently been some confusion involving acupuncture terminology. Regulatory boards have started to recognize acupuncture by other names such as dry needling and TDN. In fact, TDN and IMT are A supplement to Credentialing Resource Center Journal /12 7

8 simply re-titling and repackaging of acupuncture techniques. AAAOM includes the following specific concerns: No educational standards have been validated for physical therapists to use TDN There is a clear effort to redefine medical procedures and circumvent established standards In many states, adding TDN to the practice of physical therapy should require a legislative process In conclusion, AAAOM urges legislators, regulators, advisory boards, advocates of public safety, and medical professional associations to carefully consider the impact of these actions. AOA The American Osteopathic Association (AOA) publishes Basic Standards for Residency Training for Anesthesiology, updated in July Anesthesiology residencies are four years long and include rotations in critical care, internal medicine, surgery, pediatrics, and obstetrics and gynecology. During years two and three, residents will receive education in acute and chronic pain management, but there are no specific requirements for acupuncture. The AOA also publishes Basic Standards for Fellowship Training in Acute and Chronic Pain Management in Anesthesiology, updated in July Acute and chronic pain fellowships should be one year in length and should cover anatomy and physiology as related to pain, pain measurement, the psychological aspects of pain, general principles of pain evaluation and management, and nonsurgical techniques. However, there are no specific requirements for acupuncture. Additionally, the AOA publishes Basic Standards for Residency Training in General Neurology, updated in July Neurology residencies should be four years in length, and upon completion, residents should be qualified to perform a variety of neurology and nerve conduction procedures. However, the document does not list specific requirements for acupuncture. The AOA also publishes Basic Standards for Residency Training in Physical Medicine and Rehabilitation, updated in July Physical medicine and rehabilitation residencies should be a minimum of three years and should include osteopathic philosophy and practice in patient care. Residents should have the opportunity to observe and participate in various treatment areas, including acute musculoskeletal pain syndrome from sports and occupational injuries, chronic pain management, congenital or acquired myopathies, peripheral neuropathies, and motor system diseases. However, there are no specific requirements for acupuncture. 8 A supplement to Credentialing Resource Center Journal /12

9 ACGME The Accreditation Council for Graduate Medical Education (ACGME) publishes Program Requirements for Graduate Medical Education in Anesthesiology, revised in July Anesthesiology residencies must be a minimum of four years, consisting of one clinical base year and three years of clinical anesthesia training. The three years of clinical training includes rotations in surgical anesthesia, critical care medicine, and pain medicine. During that time residents may select additional focused educational experiences in advanced anesthesiology, including pain medicine and rehabilitation, neurology, or psychiatry. However, there are no specific requirements for acupuncture. ACGME recognizes interventional pain medicine as an evolving discipline, but training should include a minimum of 20 trigger-point injection procedures, along with image-guided injection techniques. However, there are no specific requirements for acupuncture. ACGME also publishes Program Requirements for Graduate Medical Education in Neurology, updated in July Neurological residencies must be a minimum of 48 months, including one year of broad clinical experience in general internal medicine. Residents must have at least 18 months of clinical training in adult neurology, three months of electives, three months in clinical child neurology, one month of clinical psychiatry, and experience in neuroimaging. However, the ACGME does not list specific requirements for acupuncture. Additionally, ACGME publishes Program Requirements for Graduate Medical Education in Physical Medicine and Rehabilitation, updated July Physical medicine and rehabilitation residencies are a minimum of four years, with one year of fundamental clinical skills. As part of their training, residents must have at least 12 months of outpatient clinical care, including significant experience with patients suffering from musculoskeletal disorders. Residents must also receive training in therapeutic and diagnostic injection techniques and acute and chronic pain management; however, ACGME does not list specific requirements for acupuncture. Residents in anesthesiology, neurology, and physical medicine may also choose to specialize with additional training in pain management. ACGME publishes Program Requirements for Graduate Medical Education in Pain Medicine, updated in July Pain medicine fellowships are a minimum of 12 months and focus on various aspects of pain management, including anesthesiology, neurology, physical medicine and rehabilitation, psychiatry, outpatient pain experience, inpatient chronic pain, acute pain inpatient experience, interventional experience, cancer pain, palliative pain experience, pediatrics, and advanced education in interventional pain medicine. A supplement to Credentialing Resource Center Journal /12 9

10 Positions of subject matter experts Rey Ximenes, MD Austin, Texas Although medical acupuncture is open to a wide variety of specialties, it is practiced primarily by anesthesiologists, family practitioners, neurologists, and pain management physicians due to the nature of their work, says Rey Ximenes, MD, founder and director of The Pain and Stress Management Center in Austin, Texas, and president of the AAMA. There are many different levels of medical acupuncture practitioners, which can make it difficult to differentiate competency requirements from one level to the next, Ximenes says. The most basic requirement for physicians looking to practice medical acupuncture is for the physician to be board certified and have completed an accredited residency program. Provided that requirement is met, physicians then need to complete a course in medical acupuncture with a minimum of 200 hours of training, although some courses may run as long as 300 hours. At that point you can basically do acupuncture, but you might have trouble credentialing in a hospital, Ximenes says. Most physicians complete a written test to obtain board certification through the ABMA, which serves as evidence that they have obtained the education and training to competently perform acupuncture. Some programs also offer acupuncture fellowships for additional, more comprehensive training. A hospital credentialing committee will look at the physician s medical educational background to ensure the physician has completed the requirements of his or her specialty, verify board certification in medical acupuncture, and look at any CME the physician has completed. They will also check the NPDB for any litigation surrounding acupuncture practices. Currently there is no set number of acupuncture procedures that a physician needs to perform in order to be privileged, nor are there any annual requirements for reprivileging, although Ximenes believes these requirements may be on their way. I wouldn t be surprised if that s right around the corner that they say you need do a certain number of procedure per years in the preceding year and then you need to be able to document that, he opines. I imagine that is coming. Ximenes says that hospitals know they are the deep pockets during malpractice litigation, so they are protecting themselves by developing more stringent requirements in all areas of care. He notes that when he first started as a pain 10 A supplement to Credentialing Resource Center Journal /12

11 management physician, no hospitals asked how many epidurals he had done, but now there are set requirements for all anesthesiologists. As lawsuits increase, there are more and more requirements, Ximenes says. A lot of privileging is centered around that medical-legal issue. Mark Boswell, MD, PhD, MBA Louisville, Ky. Because acupuncture is used to treat many different conditions, the background and specialty of physicians privileged for acupuncture can vary, says Mark Boswell, MD, PhD, MBA, chairman of the department of anesthesiology at the University of Louisville (Ky.), and executive director of the American Board on Interventional Pain Management. Physicians who are privileged for medical acupuncture need to undergo a minimum of 200 CME training hours, although 300 hours is preferred, Boswell says. This includes didactic training through video and several sessions where the physician learns the clinical skills of acupuncture. Hospital privileging committees should check state requirements, which sometimes stipulate a specific number of hours for acupuncture training. [In the training program] they are proctored in the beginning for needle technique and at the end according to the diagnosis, defining and emulating a treatment plan, and putting the needles in properly, Boswell says. Medical acupuncture privileges should be separate from traditional Chinese acupuncture, since medical acupuncture aims to incorporate acupuncture techniques into Western medicine practices. For example, if someone comes in with back pain, a physician is going to first have to be sure this is not back pain from a metastatic tumor before they do treatment, Boswell says. Medical acupuncture is provided in the context of medical training and management. Although physicians can still be privileged in a hospital without board certification, obtaining certification from the ABMA provides additional assurance that the physician is appropriately trained and competent to perform the procedure. There are no requirements for physicians to perform a certain number of procedures initially or annually to maintain privileges, only that they have the documented training hours, Boswell says. However, there should be some process for evaluating quality measures. It s going to be difficult in an average hospital because there won t be other A supplement to Credentialing Resource Center Journal /12 11

12 people that can determine whether someone is practicing appropriately, Boswell says. But you should have some outcome or disciplinary process to verify direct complications such as infections and so forth. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for acupuncture. However, the CMS Conditions of Participation (CoP) define a requirement for a criteria-based privileging process in (c)(6) stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges (a)(6) states, The governing body must assure that the medical staff bylaws describe the privileging pro cess. The process articulated in the bylaws, rules or regula tions must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activi ties that the majority of prac titioners in that category can perform competently and that the hospital can support. Privileges are not granted for tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. Each practitioner must be individually evaluated for requested privileges. It cannot be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are work ing within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to 12 A supplement to Credentialing Resource Center Journal /12

13 the medical staff/granted medical staff privileges ( [a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. The Joint Commission The Joint Commission has no formal position concerning the delineation of privileges for acupuncture. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). In the introduction for MS , The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS by stating, The organized medical staff is respon sible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a pro cedures list Processing the application Evaluating applicant-specific information Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privi leging decision Monitoring the use of privileges and quality-of-care issues MS further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. The EPs for standard MS include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A supplement to Credentialing Resource Center Journal /12 13

14 A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS , EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges A decision (action) on the completed application for privileges that occurs within the time period specified in the organization s medical staff bylaws Information regarding any changes to practitioners clinical privileges, updated as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). In the EPs for standard MS , The Joint Commission states that the information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from 14 A supplement to Credentialing Resource Center Journal /12

15 the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for acupuncture. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges ( ). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that individual practitioner to the governing body. It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing open-heart surgery, no physician should be granted that privilege. In the explanation for standard related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. Periodic appraisals of the suitability for membership and clinical privileges is required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed ( ). The appraisals are to be conducted at least every 24 months. The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement ( ) information must be used in the process of evaluating and acting on re-privileging and reappointment requests from members and other credentialed staff. DNV DNV has no formal position concerning the delineation of privileges for acupuncture. MS.12 Standard Requirement (SR) #1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. A supplement to Credentialing Resource Center Journal /12 15

16 The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to Clinical Privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the following circumstances: revocation/restriction of licensure; revocation, suspension, or probation of a DEA license; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding acupuncture. Minimum threshold criteria for requesting privileges in acupuncture Basic education: MD or DO Minimal formal training: Physicians may practice acupuncture under their medical license, although some state licensing boards require additional licensure for physicians to practice acupuncture. Completion of a minimum of 200 hours of formal medical acupuncture training in an approved program is required. Required current experience: Demonstrated current competence and evidence of the performance of acupuncture to at least [n] patients in the past 12 months or completion of training in the past 12 months. 16 A supplement to Credentialing Resource Center Journal /12

17 References If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. Candidates should have demonstrated current competence and evidence of the performance of acupuncture to at least [n] patients in the past 24 months based on results of ongoing professional practice evaluation and outcomes. In addition, 30 hours of CME every three years in courses on acupuncture or related topics are required. For more information Accreditation Commission for Acupuncture and Oriental Medicine Greenview Drive, Suite 300B Laurel, MD Telephone: Fax: Website: Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: Fax: Website: American Academy of Medical Acupuncture 1970 E. Grand Avenue, Suite 330 El Segundo, CA Telephone: Website: American Association of Acupuncture and Oriental Medicine 9650 Rockville Pike Bethesda, MD Telephone: Fax: Website: A supplement to Credentialing Resource Center Journal /12 17

18 American Board of Anesthesiology 4208 Six Forks Road, Suite 900 Raleigh, NC Telephone: Fax: Website: American Board of Medical Acupuncture 1970 E. Grand Avenue, Suite 330 El Segundo, CA Telephone: Fax: Website: American Board of Physical Medicine and Rehabilitation 3015 Allegro Park Lane SW Rochester, MN Telephone: Fax: Website: American Board of Psychiatry and Neurology, Inc E. Lake Cook Road, Suite 900 Buffalo Grove, IL Telephone: Fax: Website: American Osteopathic Association 142 E. Ontario Street Chicago, IL Telephone: or Fax: Website: American Osteopathic Board of Anesthesiologists 2260 East Saginaw Street, Suite B East Lansing, MI Telephone: Fax: Website: 18 A supplement to Credentialing Resource Center Journal /12

19 American Osteopathic Board of Neurology & Psychiatry 2730 S. Val Vista Drive, #146 Gilbert, AZ Telephone: Website: American Osteopathic Board of Physical Medicine and Rehabilitation 142 East Ontario Street, Floor 4 Chicago, IL Telephone: , Ext Fax: Website: Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: Website: DNV Healthcare, Inc. 400 Techne Center Drive, Suite 350 Milford, OH Telephone: Website: Healthcare Facilities Accreditation Program 142 E. Ontario Street Chicago, IL Telephone: Website: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: Fax: Website: National Center for Complementary and Alternative Medicine 9000 Rockville Pike Bethesda, MD Telephone: Fax: Website: A supplement to Credentialing Resource Center Journal /12 19

20 National Certification Commission for Acupuncture and Oriental Medicine 76 South Laura Street, Suite 1290 Jacksonville, FL Telephone: Fax: Website: World Federation of Acupuncture and Moxibustion Societies Room 516, Main Building of China Academy of Chinese Medical Science Dongzhimennei No. 16 Nanxiaojie, Beijing Telephone: Fax: Website: World Health Organization Avenue Appia Geneva 27 Switzerland Telephone: Fax: Website: Editorial Advisory Board Clinical Privilege White Papers Associate Editorial Director: Erin Callahan, Managing Editor: Julie McCoy, William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, Ga. Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, Texas Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, Calif. Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, Ariz. Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, Mo. Sally J. Pelletier, CPCS, CPMSM Director of Credentialing Services The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Danvers, Mass. The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2012 HCPro, Inc., Danvers, MA A supplement to Credentialing Resource Center Journal /12