PATIENT CARE POLICY Subject: PATIENT CARE ADMINISTRATION Title: PROVISION OF HEALTH CARE SERVICES BY PHYSICIAN- DIRECTED MID-LEVEL PROVIDERS 1 of 8 Revision of: 11/9/2005 Policy # 5.54 Effective Date: 02/25/2008 Removal Date: I. POLICY: It is the policy of Northwestern Memorial Hospital (NMH) to authorize the provision of patient care services by qualified nurses with advanced training and physician assistants with appropriate medical oversight and in accordance with the organization's bylaws and policies and Illinois law. This policy establishes the requirements with respect to approval of mid-level providers practicing within hospital facilities and applies to hospital-employed and physician-employed mid-level providers who will be providing patient care services. II. III. PURPOSE: The purpose of this policy is to describe the procedures for reviewing and approving the credentials of a mid-level provider seeking to practice within hospital facilities and to establish rules governing the mid-level provider's practice and that of his/her supervising physician. DEFINITIONS: The following definitions apply to the provisions of this policy governing mid-level providers: 1. Advanced Practice Nurse (APN): A nurse who meets all qualifications for an APN license in the State of Illinois and who signs the required scope of privileges with a member in good standing of the medical staff of Northwestern Memorial Hospital. 2. Chief of Staff (COS): The chief administrative officer and principal elected official of the organized medical staff. 3. Chief Nurse Executive (CNE): Member of hospital management responsible for nursing patient care services. 4. Credentials Committee (CC): The medical staff committee responsible for reviewing and making recommendations concerning credentialing criteria proposed for use by departments. 5. Hospital: Northwestern Memorial Hospital (NMH), Chicago, Illinois. 6. IDFPR: Illinois Department of Financial and Professional Regulation. 7. Medical Executive Committee (MEC): The executive committee of the medical staff that is accountable to the hospital Board of Directors for the overall quality of care rendered to patients at the hospital. 8. Medical Staff: The formal organization of all licensed physicians and dentists who are privileged to attend patients in the hospital. 9. Medical Staff Organizational Documents: The bylaws of the medical staff and related rules/regulations, plans and policies/procedures. 10. Mid-Level Provider (MLP): Advanced practice nurses (clinical nurse specialist, nurse practitioner, nurse midwife, registered nurse anesthetist) and physician assistants. 11. Mid-Level Provider Committee (MLPC): Multi-disciplinary hospital committee with responsibilities pursuant to this policy. 12. Peer: An individual of similar credentials and competence or greater. 13. Physician Assistant (PA): An individual with a PA degree and PA license in the State of Illinois and who agrees to work under the direction and delegation of a supervising physician. 14. Professional Standards Committee (PSC): The committee of the hospital Board of Directors responsible for patient care quality.
2 of 8 15. Scope of Privileges: Written description of the specific patient care services that may be provided by each category of MLP and qualifications. Refers to clinical functions which are services that the physician generally provides to his/her patients in the normal course of his or her current clinical medical practice, commensurate with the MLP's licensure, education, training and experience, and set forth in the scope of privileges and supervision document. 16. Senior Vice President Medical Affairs (VPMA): Member of hospital management responsible for medical affairs. 17. Supervising Physician: The medical staff member who agrees to provide the appropriate level of medical oversight, or has been designated a supervising physician for a PA by the IDFPR, and who provides medical oversight to the MLP pursuant to a scope of privileges. 18. Supervision Document: Refers to: A) A scope of privileges, and B) An anesthesia plan which is mutually agreed to by a supervising physician and a CRNA pursuant to the requirements of the Nurse Practice Act, or C) Written guidelines established by a supervising physician and a PA which meets the requirements set forth in the Physician Assistant Practice Act. 19. Suspension: Refers to a determination that an MLP shall not be permitted to exercise privileges pending review. IV. QUALIFICATIONS FOR AUTHORIZATION TO PRACTICE: Every MLP who applies for or is exercising privileges must at the time of initial application for authorization to practice and, if approved, continuously thereafter, demonstrate to the satisfaction of the hospital the following qualifications and any additional qualifications as apply to a particular MLP category. 1. Currently licensed and/or certified to practice the profession in Illinois. 2. If not hospital-employed, possess current, valid professional liability insurance, in such form and in amounts satisfactory to the hospital. 3. Relevant education and training, experience, current competence and the ability to perform privileges requested. 4. Able to satisfactorily document or demonstrate: A) Adherence to the ethics of their profession, B) Good reputation and character, C) To be free from abuse of any type of substance or chemical that interferes with, or presents a reasonable probability of interfering with, the ability to satisfy any of the qualifications required in this section or his/her ability to perform all of the privileges requested or granted, D) Ability to work harmoniously with others in the hospital environment, specifically to include refraining from conduct which constitutes a pattern of disruption such as to adversely affect the quality or efficiency of patient care services in the hospital, E) Satisfactory compliance with the Responsibilities outlined elsewhere in this policy, and F) Ability to communicate and to prepare any authorized medical records entries or other required documentation in a legible manner. V. APPLICATION FOR AUTHORIZATION TO PRACTICE: 1. Submission of Application: A) At the time that an MLP accepts employment at the hospital or a medical staff member requests authorization to practice for his/her employee, a request to release an application is submitted to the Medical Staff Administration Office. B) The hospital-employment of an MLP will be made contingent upon approval of the application. If the application is not approved, the employment of the APN in the role of an APN will be terminated or the PA will be terminated.
3 of 8 C) Physician-employed MLPs may not provide patient services at the hospital until approval is granted. D) Submission shall be on the medical staff form and shall contain a request for scope of privileges. The completed application will include copies of all documents and forms requested therein. The application will be signed by the individual seeking physiciandirected mid-level provider status and co-signed by the supervising physician. E) It is the applicant's burden to produce information deemed adequate for a proper evaluation of competence, character, ethics, and other qualifications, and of resolving any doubts about such qualifications, as well as proving that all the statements made and information given on the application are true and correct. 2. Release and immunity: By applying for authorization to practice within the hospital, the applicant expressly accepts and agrees to the following conditions (whether or not such permission is granted): A) Authorizes the hospital and its authorized representatives to consult with any third party who may have information bearing on the applicant's professional qualifications, credentials, clinical competence, character, ability to perform requested privileges, ethics, behavior, or any other matter reasonably having a bearing on the applicant's qualifications. This authorization includes the right to inspect or obtain any and all communications, reports, records, and documents from said third parties. The applicant also specifically authorizes said third parties to release information to the hospital and its authorized representatives. B) To the fullest extent permitted by law, the applicant releases from any and all liability, extends absolute immunity to, and agrees not to sue the hospital, its authorized representatives, and any third parties with respect to any acts, communications or documents, recommendations, or disclosures involving the applicant's authorization to practice and scope of practice. 3. Processing of application: Completed application is submitted to the MSA Office. The application is processed as follows: A) Physician-employed MLPs will submit the designated processing fee with the application. B) MSA Office reviews the application to determine that all questions have been answered and appropriate documentation has been received. The MSA Office verifies relevant education and training, license and/or certification, DEA registration if applicable, and obtains references to demonstrate current competence when not provided by the Human Resources Office. The MSA Office also verifies the Practitioner Data Bank Report, Federation of State Medical Boards Report (physician assistants only), Office of Inspector General Medicare/Medicaid Exclusions Report, General Services Administration Excluded Parties List, IDPA Office of Inspector General Medicaid Exclusions Report, and Office of Foreign Assets Control List. C) The MSA Office forwards the application to the Human Resources Office for criminal background check. Results are submitted to the MSA Office. D) The MSA Office transmits the completed application along with all supporting materials to the appropriate department director and clinical department chairman. E) The appropriate department director and clinical department chairman examine the application, scope of privileges requested, and all supporting information and documentation, evaluate the applicant's qualifications and current competence and make a recommendation regarding the applicant's qualifications for the requested scope of privileges. The recommendation is submitted to the MSA Office. F) The MSA Office forwards the recommendation and all supporting documentation to the CNE and VPMA for evaluation and recommendation. G) The CNE submits the recommendation to the MEC.
4 of 8 H) The MEC submits recommendation to PSC. I) The PSC renders a final decision regarding authorization to practice and scope of privileges. 4. Preliminary approval for authorization to practice: An applicant may be eligible for preliminary approval for authorization to practice during the application processing period. If the following standards are met, the CNE and VPMA may grant preliminary approval to exercise privileges: A) The applicant submits a complete application which provides all required information and all verification procedures have been completed and found satisfactory, B) The scope of privileges requested is consistent with standard privileges for the category of MLP, C) There are no current or previously successful challenges to the applicant s licensure or registration, D) The applicant has not been subject to any summary suspension or involuntary termination, limitation, reduction, denial or loss of employment, membership or privileges at any hospital, physician practice, or other healthcare entity, E) There has not been a final adverse judgment entered against the applicant in a professional liability action, and F) There is not a criminal background history. In all other cases, the process stated in Section V.3. shall be followed. The CNE and VPMA retain discretion to refer any application for any reason to the MLPC or the medical staff Credentials Committee for additional review and input. VI. COMPETENCE ASSESSMENT: Mid-level practitioners will undergo continued assessment of competence and ability to perform their jobs on an annual basis by the supervising physician. The competence assessment will include peer review and renewal of scope of privileges on a biennial basis. An assessment of any age-specific requirements or special needs/behaviors or competence measures, occur as determined by Patient Care Administration of the hospital. MLPs are subject to the hospital s performance improvement process. VII. NEW CATEGORIES OF MLPS OR INCREASED SCOPE OF PRIVI-LEGES FOR CURRENT CATEGORIES OF MLPS: 1. The following categories of MLPs are permitted to provide patient care services in the hospital pursuant to applicable law and this policy: A) Advanced practice nurse/certified clinical nurse specialist B) Advanced practice nurse/certified nurse practitioner C) Advanced practice nurse/certified nurse midwife D) Advanced practice nurse/certified registered nurse anesthetist E) Physician assistant 2. The MLP is employed by the hospital or a medical staff member (or the medical staff member's group). 3. For new categories of MLPs or increased scope of privileges for current categories of MLPs: A) A written request must be submitted to the MLPC through the Chief Nursing Executive and the CC through the Medical Staff Administration Manager. The request must include a statement outlining the reason for the additional category, a statement of qualifications, and the proposed scope of privileges.
5 of 8 VIII. B) The MLPC shall review the request, obtaining input as appropriate from the applicable department chairs, chiefs and department directors, and shall transmit its recommendation regarding the category, qualifications, and the scope of privileges to the CC and then the MEC. C) The CC and MEC shall conduct a similar review and may refer back to the MLPC or department chair for additional input or shall forward its recommendation to the PSC. D) If the recommendation of either the CC or the MEC is not unanimous, the nature of and reason for the dissenting view must be documented and transmitted with the majority's recommendation. E) The PSC shall review the recommendations and dissenting views if any. It may refer the matter back for additional input and subsequent recommendations or shall take action to approve or deny the request. RESPONSIBILITIES: 1. Each MLP shall: A) Provide patients with patient care services pursuant to scope of privileges at the level of quality and efficiency professionally recognized as the appropriate standard of care by the Medical Staff. B) Participate in quality assessment/improvement program activities as appropriate. C) Abide by and be subject to the applicable sections of the medical staff bylaws, rules and regulations, and policies and procedures and all other policies and procedures and rules of the hospital. D) Prepare and complete in a timely fashion, as appropriate and authorized, those portions of patients' medical records documenting services provided and any other required records. E) At all times while on hospital premises, wear a name tag clearly identifying him/herself by name and professional designation and not represent to patients that s/he is a physician. F) Maintain at all times in Medical Staff Administration evidence of current Illinois license, controlled substance and DEA licenses, certification, professional liability certificate of insurance, as required. G) Immediately notify the CNE and the VPMA, of: 1) Any criminal charges brought against the MLP (other than minor traffic violations not involving a DUI charge), 2) Any charge made or formal action initiated that could result in a change to the status of license to practice, professional liability insurance coverage, ability to participate in Medicare, Medicaid or any other government funded programs, all changes in employment or affiliation relationships involving a termination, disciplinary action or reduction in privileges with the supervising physician, affiliation with or patient care services at other institutional affiliations where s/he provides patient care services, 3) Any change in the status of current or initiation of new malpractice claims involving his/her professional performance, and 4) Any change in health or mental status that would affect his/her ability to perform safe patient care. H) Refrain from any conduct or acts that are or could reasonably be interpreted as being beyond, or an attempt to exceed, the scope of privileges authorized within the hospital. I) Failure to satisfy any of these obligations is grounds, as warranted by the circumstances, for termination of authorization to practice or for such other disciplinary action as deemed appropriate. 2. Any physician supervising an MLP in the care of patients shall: A) Be a member of the medical staff of the hospital and will function as a supervising physician in accordance with all bylaws, organizational documents, policies and rules of the hospital
6 of 8 and Medical Staff, and for the correction and resolution of any problems that may arise. Visiting staff may not serve as supervising physicians. B) Abide by all bylaws, policies and rules governing the use of MLPs in the hospital and the MLP's authorized scope of privileges in the hospital. C) Be available in person or by telephone to provide consultation on medical problems, complications, or emergencies. In the case of CRNAs, an attending anesthesiologist must be physically present and available on the premises for diagnosis, consultation and treatment of emergency conditions during the delivery of anesthesia services. As for CRNAs, the physician administrator for the Department of Anesthesia accepts administrative responsibility for the CRNAs and assures that appropriate supervision and anesthesia plan are provided by the team of anesthesiologists responsible for anesthesia services on any given day. D) Provide supervision of the MLP consistent with the Physician Assistant Practice Act and/or the Nurse Practice Act. E) Maintain responsibility for directing the course of the patient's medical treatment. (For CRNAs, this section is subject to Section C.) F) Will not represent to patients and hospital staff that the MLP is an employee or agent of NMH (except if hospital-employed). G) Immediately notify the CNE and VPMA in the event any of the following occur: 1) The supervision document or the nature of his/her professional arrangement with the MLP changes. 2) His/her approval to supervise the MLP is revoked, limited, or otherwise altered by action of the IDFPR. 3) Notification is given of investigation of the MLP or of his /her supervision of the MLP by the IDFPR. 4) His/her professional liability insurance coverage is changed insofar as coverage of the acts of the MLP is concerned or the MLP's professional liability insurance coverage is changed. H) Acknowledge these obligations in writing. IX. LIMITATIONS: MLPs are not: 1) eligible to become members of the Medical Staff; 2) eligible to attend or vote in meetings of, or hold office on the Medical Staff; 3) eligible for admitting privileges. Additionally, limitations may be placed on the MLP's authorized scope of privileges in the hospital as deemed necessary either for the efficient and effective operation of the hospital or any of its departments or services, or for management of personnel, services and equipment, or for quality or efficient patient care, or as otherwise deemed by the hospital to be in the best interests of patient care or the hospital. X. TERMS AND CONDITIONS OF AUTHORIZATION TO PRACTICE: An MLP shall be assigned to the clinical and/or hospital department appropriate to his/her professional training and authorized scope of privileges. The MLP is subject to periodic competency assessment and disciplinary actions as deemed appropriate. MLPs and their supervising physicians are subject to review as part of the organization's peer review and performance improvement activities. An MLP's authorized scope of privileges within any clinical department/section is subject to the rules and regulations of that department/section and to the authority of the chairman/chief and the department director. When a supervising physician is unable or unavailable to be the principal medical decision maker, another licensed physician must be designated to assume temporary supervisory responsibilities with respect to the MLP. For periods of one month or less, the supervising physician may designate a temporary replacement. For periods longer than one month, the MLP and supervising
7 of 8 physician must notify the Chief Nursing Executive, the appropriate department chair/chief and the MSA Office of the need to replace the supervising physician. If no temporary or replacement supervising physician is available, authorization to practice as an MLP automatically terminates. If employment (by NMH or physician) is terminated, authorization to practice as an MLP automatically terminates. If the supervising physician terminates medical staff membership, refuses to renew or terminates a supervision document, authorization to practice as an MLP automatically terminates. If the MLP is employed by another NM affiliated organization or physician, authorization to practice is suspended pending update of scope of privileges, supervising physician acknowledgement statement, and professional liability insurance. Suspension shall not exceed thirty (30) days. If the supervising physician's approval to supervise the MLP is revoked, limited, or otherwise altered by action of the IDFPR, authorization to practice as an MLP is automatically revoked, limited or otherwise altered. If the MLP is suspended from Medicare, Medicaid or any other government funded program, an automatic suspension of privileges shall result and shall continue until satisfactory evidence of the completion of such suspension is received. If the MLP is finally excluded and terminated from Medicare, Medicaid or any other government funded program, there is an automatic termination of all privileges. XI. CORRECTIVE ACTION AND FAIR HEARING: Either the CNE or VPMA may impose a suspension of the practice of an MLP at any time it is deemed in the best interest of patient care and of the hospital. The physician-employed MLP and supervising physician may request a review by the MLPC. The MLPC may require the submission of additional information from any relevant source. The MLP and supervising physician are informed of the general nature and circumstances giving rise to the review. The MLP and supervising physician will be granted the opportunity to discuss the situation with the MLPC who shall make a recommendation to the CNE and VPMA. Thereafter a final ruling will be made by the CNE and VPMA. A hospital-employed MLP will follow the hospital grievance process. Nothing contained in this policy or the medical staff organizational documents shall be interpreted to entitle a mid-level provider to the procedural rights set forth in the medical staff organizational documents. XII. MID-LEVEL PROVIDER COMMITTEE: 1. Structure: The MLPC is appointed by the CNE who shall serve as the committee chairperson. Committee membership shall include at least one physician from the medical staff Credentials Committee who shall be appointed by the COS, a certified nurse practitioner, a certified nurse midwife, a certified clinical nurse specialist, a certified registered nurse anesthetist and a certified physician assistant. 2. Function: The MLPC reviews and renders recommendations regarding credentials files referred to it by the CNE and VPMA. The MLPC evaluates requests for new categories of MLPs or increased scope of privileges for current categories of MLPs. The MLPC may review a corrective action of an MLP, if requested.
8 of 8 XIII. APPROVAL: Responsible Party: Jill Rogers Director, Professional Practices and Development Reviewers: Manager, Medical Staff Administration Directors, Patient Care Office of General Counsel Committees: Mid-Level Provider Committee Credentials Committee, February 7, 2008 Medical Executive Committee, February 11, 2008 Professional Standards Committee, February 22, 2008 Approval Parties: Michelle Janney Senior Vice President and Chief Nurse Executive Electronically Approved: Chuck M. Watts Senior Vice President, Medical Affairs Electronically Approved: Dean M. Harrison President and CEO Northwestern Memorial Hospital Electronically Approved: NMH Board, February 25, 2008 XIV REVIEW HISTORY: Revised: 02/25/2008 Revised: 11/09/2005