Practice area 177 Clinical PRIVILEGE WHITE PAPER Background Supplement: Scope of practice for massage therapists According to the National Center for Complementary and Alternative Medicine, massage therapists rub and manipulate the muscles and other soft tissues of the body. Patients use massage therapy to relieve pain, rehabilitate sports injuries, reduce stress, increase relaxation, address anxiety and depression, and promote general health. According to the 2007 National Health Interview Survey, 8.3% of adults and 1% of children had used massage. According to the American Massage Therapy Association (AMTA), the four most common types of massage are: Swedish massage to promote relaxation and increase energy Deep tissue massage for muscle damage from an injury, such as whiplash or back strain Sports massage to help prevent athletic injury, keep the body flexible, and heal the body should injury occur Chair massage, which is a massage of the upper body that occurs while the patient is fully clothed and seated in a portable chair State regularly board or local licensing authorities may require massage therapists to hold a license. No matter which entity requires the license, a massage therapist cannot practice unless he or she has one. For more information, visit the AMTA s website (www.amtamassage.org/regulation/stateregulations.html), which links to state regulations. In addition, many massage therapists also choose to become nationally certified in massage therapy. The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) administers national certification. Involved specialties Massage therapists Positions of certification boards FSMTB The Federation of State Massage Therapy Boards (FSMTB) supports member boards that work to ensure that the practice of massage therapy is provided to the A supplement to Credentialing Resource Center Journal 781/639-1872 07/11
public in a safe and effective manner. The federation developed the Massage & Bodywork Licensing Examination (MBLEx) on behalf of its member boards to provide a valid, reliable licensing examination to determine entry-level competence. To find out which states use MBLEx, visit www.fsmtb.org. The site also contains links to individual state massage therapy licensing boards. NCBTMB The NCBTMB is an independent, private, nonprofit organization that was founded in 1992 to establish a certification program and uphold a standard of excellence. A candidate can become eligible to take the certifying exam in one of three ways: the education/training process, the portfolio review process, and the National Examination for State Licensing (NESL) option. To become eligible to take the exam via the education/training process, the candidate must have completed a minimum of 500 hours of instruction from a qualified school. The program must have included 300 hours of instruction delivered in class, through distance education, or via a combination of both. It must also include 200 hours of hands-on instruction delivered in class (face-to-face only). The program of instruction must include: 200 hours of massage and bodywork assessment, theory, and application instruction A minimum of 125 hours of instruction on the body systems (anatomy, physiology, and kinesiology) 40 hours of pathology 10 hours of business and ethics instruction (a minimum of six hours in ethics) 125 hours of instruction in an area or related field that theoretically completes the candidate s massage program of study A candidate can apply to take the exam through the portfolio review process if his or her program of study does not meet the above requirements. Students who attend a school outside of the United States must apply through the portfolio review process. This process lets candidates put together a portfolio of all of their training. The portfolio review team reviews the portfolio to see whether a candidate s training is equivalent to the training he or should receive in a formal 500- hour program. To become eligible for certification via the NESL option, candidates can: Test prior to having satisfied the 500-hour requirement Test prior to graduating from a program Convert to a national certification within two years of passing the exam under the NESL option once the candidate has: 2 A supplement to Credentialing Resource Center Journal 781/639-1872 07/11
Met the 500-hour requirement Graduated from his or her program Agreed to adhere to the NCBTMB s Code of Ethics Completed a conversion form Submitted an official transcript mailed from the candidate s school NCBTMB certificate holders must recertify every four years based on the certification expiration date. Certificate holders are required to submit 48 continuing education hours related to massage therapy and 200 hours of work experience completed during the cycle. Positions of societies, academies, colleges, and associations AMTA According to the AMTA, massage therapy credentials include licensing, national certification, education and training with an accredited school, and membership in a professional association. According to the association, most states regulate the massage therapy profession. Depending on the state, this could be in the form of a license, registration, or certificate. Cities, counties, or other local governments may also regulate massage. It is illegal for anyone to work as a massage therapist unless he or she has a license, registration, or certificate. The AMTA recommends a minimum of 500 hours of supervised, in-class initial massage therapy training, which must include the study of anatomy and physiology, the theory and practice of massage therapy, and elective subjects. According to the AMTA, statewide massage therapy regulation will define the minimum initial massage therapy training requirement. Most states require a minimum of 500 hours of training, but some require 1,000 hours of training. Membership in a credible professional association such as the AMTA further indicates professional preparation and accountability. The association requires its members to meet minimum education requirements, pursue continuing education, and uphold its code of ethics. Professional members of the AMTA demonstrate their competency by completing one or more of the following: Graduation from a minimum 500-hour in-class, entry-level massage therapy school Proof of current state or provincial licensure, where applicable Certification by the NCBTMB A supplement to Credentialing Resource Center Journal 781/639-1872 07/11 3
AMTA members also adhere to a professionally recognized code of ethics and standards of practice, and continue their professional education and development. Positions of accreditation bodies CMS CMS has no formal position regarding the delineation of privileges for massage therapy. The Joint Commission Note: The following references The Joint Commission Human Resource Standards. Refer to the Comprehensive Accreditation Manual for Hospitals for more on the HR standards. The Joint Commission has no formal position concerning the scope of practice for massage therapists. According to The Joint Commission s Comprehensive Accreditation Manual for Hospitals, HR standards apply to all staff (e.g., employees, contractors, nonemployees who provide care) who provide services in the healthcare organization. The following EP has particular relevance to understanding the credentialing process for nonprivileged practitioners such as the massage therapist. HR.01.02.05, EP 7 states, Before providing care, treatment, and services, the hospital confirms that nonemployees who are brought into the hospital by a licensed independent practitioner [LIP] to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital. Two additional notes further define this EP. The first note states that the confirmation of qualifications and competencies can be accomplished through the hospital s regular process or with the LIP who brought in the individual. The second note specifies that if the care, treatment, and services by the nonemployee are not currently performed by anyone employed by the hospital, leadership must consult appropriate professional hospital guidelines for the required credentials and competencies. The following HR standards are also applicable: The hospital has the necessary staff to support the care, treatment, and services it provides (HR.01.01.01). The hospital defines staff qualifications specific to their job responsibilities (HR.01.02.01). The hospital verifies staff qualifications (HR.01.02.05). EPs 1 5 state that the following is verified and documented in accordance with law, regulation, and hospital policy at the time of hire and when a staff member s credentials are renewed as applicable: 4 A supplement to Credentialing Resource Center Journal 781/639-1872 07/11
Current license, certification, or registration Education and experience Criminal background check Health screening The information listed in the previous bullet is used to make decisions regarding staff job responsibilities (HR.01.02.05, EP 6). The hospital determines how staff function within the organization (HR.01.02.07). EPs 1 2 state that staff who provide care, treatment, or services possess a current license, certification, or registration if required by law and regulation, and practice within the scope of that license, certification, or registration. The hospital provides orientation to staff (HR.01.04.01). EPs 1 6 state that: The hospital determines the key safety content of orientation provided to staff The hospital orients its staff to the key safety content before staff provide care, treatment, and services; completion of this orientation is documented The hospital orients staff on the following and it is documented: relevant hospitalwide and unit-specific policies and procedures; specific job duties (including those related to infection prevention and control and managing pain); sensitivity to cultural diversity based on job duties and responsibilities; and patient rights, including ethical aspects of care, treatment, and services Staff participate in ongoing education and training (HR.01.05.03). EPs 1 13 (note that EPs 3 and 9 12 do not exist) state that staff participate in ongoing education and training (and their participation is documented): To maintain or increase their competency. Whenever staff responsibilities change. Specific to the needs of the patient population served by the hospital That incorporates the skills of team communication, collaboration, and coordination of care. That includes information about the need to report unanticipated adverse events and how to report the event. On fall reduction activities. That addresses early warning signs of a change in a patient s condition and how to respond to a deteriorating patient, including how and when to contact responsible clinicians. Education is provided to staff and LIPs who may request assistance and those who may respond to those requests. This education and training is documented. Staff are competent to perform their responsibilities (HR.01.06.01). EPs 1 15 (note that EPs 7 14 do not exist) state that the hospital: Defines the competencies it requires of staff who provide care. Uses assessment methods to determine the individual s competence in the skills being assessed. Methods may include test-taking, return demonstration, or the use of simulation. Assesses skills utilizing an individual with the educational background, experience, or related knowledge. When a suitable individual cannot be found to A supplement to Credentialing Resource Center Journal 781/639-1872 07/11 5
assess staff competence, the hospital can utilize an outside individual for this task. Alternatively, the hospital may consult the competency guidelines from an appropriate professional organization to make its assessment. Conducts an initial assessment of staff competence as a part of orientation and this assessment is documented. Assesses and documents staff competence once every three years, or more frequently as required by hospital policy or in accordance with law or regulation. Takes action when a staff member s competence does not meet expectations. The hospital evaluates staff performance (HR.01.07.01). EPs 1 3 state that the hospital: Evaluates staff based on performance expectations that reflect their job responsibilities. Evaluates staff performance and documents the evaluation once every three years, or more frequently as required by hospital policy or in accordance with law or regulation. Reviews competencies and performance for nonemployed individuals brought into the facility by an LIP at the same frequency as hospital employees. This can be accomplished either with the LIP or through the hospital s regular process. CRC draft criteria Healthcare organizations must understand applicable regulatory and accreditation requirements when it comes to credentialing privileged and nonprivileged practitioners. This supplemental white paper cannot and does not cover all of the necessary decision points. Find additional information in the following resources: Solving the AHP Conundrum Core Privileges for AHPs The Comprehensive Healthcare Job Descriptions Manual The focus of this supplemental white paper is on practitioners (e.g., massage therapists) who are not permitted to function independently or who are not required to be privileged through the medical staff process but must be authorized through the HR process in order to provide clinical care to patients. This process is similar or identical to that used for employed staff to ensure that all individuals who are providing services in the organization are appropriately credentialed meaning they are competent and appropriately trained to carry out their responsibilities. When defining a scope of practice or job description for nonprivileged practitioners, hospitals should take full advantage of internal sources, such as the job descriptions HR already uses for employees performing the same or similar functions. 6 A supplement to Credentialing Resource Center Journal 781/639-1872 07/11
The following draft qualifications and scope of practice are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. This scope of practice is not meant to be all-encompassing, but rather to define the types of activities that massage therapists perform. Each facility may uniquely define the roles and responsibilities of a massage therapist as applicable to meet its needs and scope of services and in accordance with state regulations. The customization of the qualifications (criteria) and an accompanying scope of practice should be incorporated into the hospital s existing job description format. Applicants must meet the same minimum threshold job requirements that are required to be employed as a massage therapist. Those minimum requirements may include the following: Minimal formal training: Successful completion of 500 hours of massage therapy training, which must include the study of anatomy and physiology, the theory and practice of massage therapy, and elective subjects. Required current experience: Applicants must demonstrate that they have performed at least 50 therapeutic sessions of massage/body work in the past 12 months in the massage specialty for which they are requesting privileges. Current certification is required. Continuous competency assessment: Applicants are subject to an [annual] competency assessment and must be able to demonstrate current clinical competence. Job summary The scope of practice for a massage therapist would be defined based on the type of massage performed, such as but not limited to the following: Swedish massage to promote relaxation and increase energy Deep tissue massage for muscle damage from an injury, such as whiplash or back strain Sports massage to help prevent athletic injury, keep the body flexible, and heal the body should injury occur Chair massage, which is a massage of the upper body that occurs while the patient is fully clothed and seated in a portable chair For more information American Massage Therapy Association 500 Davis Street Evanston, IL 60201 Telephone: 877/905-0577 Website: www.amtamassage.org A supplement to Credentialing Resource Center Journal 781/639-1872 07/11 7
Federation of State Massage Boards 7111 West 151st Street, Suite 356 Overland Park, KS 66223 Telephone: 888/70-FSMTB Fax: 913/681-0391 Website: www.fsmtb.org The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 Telephone: 630/792-5000 Fax: 630/792-5005 Website: www.jointcommission.org National Center for Complementary and Alternative Medicine National Institutes of Health 9000 Rockville Pike Bethesda, MD 20892 Telephone: 888/644-6226 Website: nccam.nih.gov National Certification Board for Therapeutic Massage and Bodywork 1901 South Meyers Road, Suite 240 Oakbrook Terrace, IL 60181 Telephone: 630/627-8000 Website: www.ncbtmb.org Editorial Advisory Board Clinical Privilege White Papers Associate Group Publisher: Erin Callahan, ecallahan@hcpro.com Associate Editor: Julie McCoy, jmccoy@hcpro.com 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, TX Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, CA Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, AZ 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, MA Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Danvers, MA Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Danvers, MA 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 2011 HCPro, Inc., Danvers, MA 01923. 8 A supplement to Credentialing Resource Center Journal 781/639-1872 07/11