CLINICAL PRIVILEGE WHITE PAPER

Practice area 166 CLINICAL PRIVILEGE WHITE PAPER Chiropractor Background Chiropractic, a profession dating back to the 1890s, examines the relationship between the spine and nervous system and attempts to correct health problems through manipulation or adjustment of the musculoskeletal system or, more specifically, the vertebrae of the spine. Many ailments are caused by the vertebrae impinging on the spinal nerve, creating interferences with normal nerve transmission. When such subluxations are corrected, proper vertebral alignment and normal brain and nerve transmission are restored, enabling the body to resume its innate ability to recover from illness. The practice and procedures that a Doctor of Chiropractic (DC) may employ are based on the academic and clinical training received at accredited chiropractic colleges, and include, but are not limited to, the use of current diagnostic and therapeutic procedures. Such procedures specifically include the adjustment and manipulation of the articulations and adjacent tissues of the human body, particularly of the spinal column. Today, most practicing providers mix spinal adjustments with other therapies, such as hot or cold treatments, nutrition counseling, and exercise recommendations. They also frequently use new technologies to locate and eliminate subluxations. Two years of undergraduate studies are required to be eligible for admission to a chiropractic college, according to the Commission on Accreditation of the Council on Chiropractic Education (CCE). Students of chiropractic earn their DC degree after completing four years of training at one of the nation s 18 chiropractic colleges accredited by the CCE. Some states require chiropractors to have a bachelor s degree and a chiropractor degree to practice. Graduates from six foreign programs two in Australia, two in Canada, one in England, and one in France are also recognized by the CCE. Chiropractors are regulated at two levels. First, the National Board of Chiropractor Examiners (NBCE) conducts board certification of chiropractors, thereby creating national standards for chiropractic care. Second, licensure takes place at the state level in accordance with specific state laws, which may differ significantly from state to state. Most states require successful completion of the NBCE examination prior to licensure. Some states also require licensure candidates to pass a practical examination. All states recognize training from chiropractic schools accredited by the CCE. Most states have requirements for a certain number of continuing education hours to be completed every year in order to maintain licensure. Independent certifying boards, called councils, also certify chiropractors in various A supplement to Briefings on Credentialing 781/639-1872 03/07

specialties if they choose to augment their general chiropractic skills. Examples of diplomates are therapeutic rehabilitation, family practice, diagnostic imaging, behavioral health, neurology, nutrition, occupational health, and orthopedics. The American Chiropractic Association (ACA) sponsors 12 diplomate programs that are both residency (i.e., nonhospital) and nonresidency in nature. Each specialty council has its own oral, written, and practical exam that chiropractors must pass in order to claim proficiency in a specialty area. Involved specialties Chiropractors Positions of societies and academies ACA The ACA has adopted guidelines and a program for doctors of chiropractic who seek inclusion on the staffs of hospitals and other healthcare institutions. For the mutual benefit of healthcare institutions and the chiropractic profession, the ACA recommends that its guidelines be formally adopted as policy for doctors of chiropractic who seek staff privileges. The ACA proposes the following guidelines for chiropractors who seek to be integrated into the established hospital system: Chiropractors must fit into the existing mechanisms, plans, and protocols of hospital staffing. Hospital staff members generally stay within their limited specialties and call upon consultants for problems outside of those specialties. Chiropractors will secure entrance into hospitals only by working within the system. The logical point of entry is to seek admission for the neuromusculoskeletal disorders most commonly treated by the majority of chiropractors. They would perform related examinations, order related x-rays, perform manipulative procedures (i.e., adjustments), order physical therapy, and provide other supportive measures, all within the scope of existing state laws governing the practice of chiropractic. In conjunction with the ACA s general objectives and stated guidelines, the following additional limited objectives are currently recommended: Within the legal scope of practice, utilize diagnostic facilities and procedures for responsible differential diagnosis as essential to management, comanagement, or referral of the patient Utilize chiropractic manipulation, physical therapy, external immobilization, and nutrition where applicable 2 A supplement to Briefings on Credentialing 781/639-1872 03/07

Provide, when needed, training in hospital protocol and procedures through CCE-approved programs in one of the ACA s accredited colleges Provide for screening procedures of chiropractic applicants with consideration of education, training, scope of practice, reputation, and ability to work in harmony with medical and other hospital personnel Refer to medical specialists for management of infectious, neoplastic, or primary neurologic disease ICA The International Chiropractors Association (ICA) does not take a position on the privileging of chiropractors. However, in its policy statement The Practice of Chiropractic, the ICA states that chiropractic spinal adjustment is unique and singular to the chiropractic profession due to its specificity of application and rationale for application. The ICA also states that DCs are portal of entry, primary healthcare providers and, as such, are well-educated in the basic, clinical, and chiropractic sciences and other health-related areas. DCs are trained in physical, clinical, laboratory, analytical, and diagnostic procedures, as well as in the monitoring of body functions, thus enabling them to responsibly and effectively care for patients, engage in timely consultation with other healthcare professionals, and refer and accept referrals when in patients best interests. In addition, the ICA recognizes that state legislatures have the right to grant DCs the option to qualify and thereafter use procedures that are not within the ICA s view of the parameters of the clinical application of traditional chiropractic. Although it respects individual and state rights, the ICA believes that it is in the best interest of the chiropractic profession and the public to advocate and promote a standardized and consistent scope of practice worldwide. Positions of other interested parties CCE The following colleges have achieved accredited status with the CCE: Cleveland Chiropractic College of Kansas City (MO) Cleveland Chiropractic College of Los Angeles Life University School of Chiropractic, Marietta, GA Life University School of Chiropractic West, Hayward, CA Life Chiropractic College West, San Lorenzo, CA Logan College of Chiropractic, Chesterfield, MO A supplement to Briefings on Credentialing 781/639-1872 03/07 3

Los Angeles College of Chiropractic, Whittier, CA The National College of Chiropractic, Lombard, IL New York Chiropractic College, Seneca Falls Northwestern College of Chiropractic, Bloomington, MN Palmer College of Chiropractic, Davenport, IA Palmer College of Chiropractic Florida, Port Orange Palmer College of Chiropractic West, San Jose, CA Parker College of Chiropractic, Dallas Sherman College of Straight Chiropractic, Spartanburg, SC Texas Chiropractic College, Pasadena University of Bridgeport (CT) College of Chiropractic Western States Chiropractic College, Portland, OR Anglo-European College of Chiropractic, Dorset, England Canadian Memorial Chiropractic College, Toronto, Ontario Institut Francais de Chiropractie, Paris, France Maquarie University, Center for Chiropractic Studies, Summerhill, Australia Royal Melbourne Institute Technology, Chiropractic Unit, Bundoora, Australia University of Quebec at Trois-Rivieres (Quebec) NBCE FCLB According to the NBCE, to become doctor of chiropractic, an individual must meet stringent academic and professional requirements that include passing nationally standardized examinations. Currently, an individual must complete the following steps to become a licensed chiropractor: 1. Complete two years of general college-level study (some states require a bachelor s degree) 2. Obtain a DC degree and complete a clinical externship through a CCE-accredited four-year chiropractic college training program 3. Pass the NBCE/other state-required examinations 4. Satisfy any other individual state-specific requirements for licensure Specific information on the licensure and regulations governing chiropractors in each state can be found in the Federation of Chiropractic Licensing Boards (FCLB) annual Official Directory: Chiropractic Licensure and Practice Statistics. In addition, the FCLB maintains a searchable database called CIN-BAD, which serves as a repository of information on actions taken by official bodies with regard to individual chiropractors. Data received from the FCLB s member boards and the U.S. Department of Health and Human Services provides 4 A supplement to Briefings on Credentialing 781/639-1872 03/07

users with a practitioner s name, date of birth, Social Security number, licensure information, educational degrees, diplomate status or certification, licensure in other professions, board actions, and Medicare exclusions. The Joint Commission The Joint Commission has no formal position concerning the delineation of privileges for chiropractors. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states (MS.4.10), The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege. In the rationale for MS.4.10, The Joint Commission states that there must be a reliable and consistent process in place to process applications and verify credentials. The organized medical staff then reviews and evaluates the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission further states (MS.4.20), 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. In the elements of performance for standard MS.4.20, The Joint Commission says that the information review and analysis process is clearly defined. 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 Joint Commission further states (MS.4.40), 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. In the elements of performance for MS.4.40, The Joint Commission says there is a clearly defined process that facilitates 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. A supplement to Briefings on Credentialing 781/639-1872 03/07 5

Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. CRC draft criteria A hospital should not wait until it receives a request for an application for clinical privileges from a chiropractor to consider whether it wishes to grant privileges to this type of practitioner. The policy covering chiropractors should be drafted ahead of time by the board and should consider state laws, the needs of the community, the medical staff, and the hospital s mission and strategic plan. Criteria should be in place covering qualifications, scope of practice, and physician supervisory requirements. The criteria and process for granting clinical privileges to chiropractors should be outlined in an appropriate document. The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. Minimum threshold criteria for requesting core privileges in chiropractic Basic education: Two years of general college-level study (some states require a Bachelor s degree) Minimum formal training: Applicants must be able to demonstrate successful completion of a CCE-accredited four-year chiropractic college training program. In addition, a chiropractor should meet the following requirements: Successful completion of the examination offered by the NBCE Current licensure to practice as a chiropractor issued by the state board of chiropractic examiners Possession of professional liability insurance coverage issued by a recognized company and of a type and in an amount equal to or greater than the limits established by the facility s governing board (if applicable to the facility) Provision of services in accordance with written policies and protocols governing allied health professionals developed and approved by the relevant clinical department or service, the facility s medical executive committee, and the facility s governing board Required previous experience: Current demonstrated competence and an adequate volume of current experience, documenting the ability to provide services at an acceptable level of quality and efficiency. 6 A supplement to Briefings on Credentialing 781/639-1872 03/07

References Core privileges A letter of reference should come from the director of the applicant s chiropractic training program. Alternately, a letter of reference should come from the supervising physician at the institution where the applicant most recently practiced. Core privileges in chiropractic include performance of an initial case history limited to neuromusculoskeletal injuries and diseases with direct chiropractic implications, as well as manipulative adjustments both diversified and specific as taught in accredited chiropractic colleges. Privileges also include, but are not limited to, the following: Order lab tests related to possible musculoskeletal disorders on both inpatients and outpatients. (Abnormal results that are out of the realm of a chiropractor require referral or consultation to an MD/DO on the medical staff.) Order radiographic and nuclear medicine studies in order to evaluate musculoskeletal pain or disability on inpatients and outpatients. (Abnormal results that are out of the realm of a chiropractor require referral or consultation to an MD/DO on the medical staff.) Prescribe physical and occupational therapy for inpatients and outpatients. A chiropractor who wishes to use physical therapy equipment or space may do so only after first clearing such use with the director of physical therapy and in consultation, as necessary, with the chief of the medical staff. Reappointment Reappointment should be based on unbiased, objective results of care according to the organization s quality assurance mechanisms. Applicants also must be able to demonstrate that they have maintained competence by showing evidence that they have met the continued competence requirements established by the state licensing authority, applicable to the functions that they seek to provide at the hospital. In addition, continuing education related to chiropractic should be required. A supplement to Briefings on Credentialing 781/639-1872 03/07 7

For more information For more information regarding this practice area, contact: American Chiropractic Association 1701 Clarendon Blvd. Arlington, VA 22209 Web site: www.acatoday.org Council on Chiropractic Education 8049 North 85th Way Scottsdale, AZ 85258-4321 Telephone: 480/443-8877 Fax: 480/483-7333 Web site: www.cce-usa.org Federation of Chiropractic Licensing Boards 5401 W. 10th St., Suite 101 Greeley, CO 80634-4400 Telephone: 970/356-3500 Fax: 970/356-3599 Web site: www.fclb.org International Chiropractors Association 1110 North Glebe Rd., Suite 1000 Arlington, VA 22201 Telephone: 703/528-5000 Fax: 703/528-5023 Web site: www.chiropractic.org The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 Telephone: 630/792-5000 Fax: 630/792-5005 Web site: www.jcaho.org National Board of Chiropractic Examiners 901 54th Ave., Suite 101 Greeley, CO 80634-4400 Telephone: 970/356-9100 Fax: 970/356-6134 Web site: www.nbce.org 8 A supplement to Briefings on Credentialing 781/639-1872 03/07

Privilege request form Chiropractor In order to be eligible to request clinical privileges in chiropractic, an applicant must meet the following minimum threshold criteria: Basic education: Two years of general college-level study (some states require a Bachelor s degree) Minimum formal training: Successful completion of a CCE-accredited chiropractic training program. In addition, a chiropractor should meet the following requirements: Successful completion of the examination offered by the NBCE Current licensure to practice as a chiropractor issued by the state board of chiropractic examiners Possession of professional liability insurance coverage issued by a recognized company and of a type and in an amount equal to or greater than the limits established by the facility s governing board (if applicable to the facility) Provision of services in accordance with written policies and protocols governing allied health professionals developed and approved by the relevant clinical department or service, the facility s medical executive committee, and the facility s governing board Required previous experience: Current demonstrated competence and an adequate volume of current experience, documenting the ability to provide services at an acceptable level of quality and efficiency. References: A letter of reference should come from the director of the applicant s chiropractic training program. Alternately, a letter of reference should come from the supervising physician at the institution where the applicant most recently practiced. Core privileges: Core privileges in chiropractic include performance of an initial case history limited to neuromusculoskeletal injuries and diseases with direct chiropractic implications, as well as manipulative adjustments both diversified and specific as taught in accredited chiropractic colleges. Privileges also include, but are not limited, to the following: Order lab tests related to possible musculoskeletal disorders on both inpatients and outpatients. (Abnormal results that are out of the realm of a chiropractor require referral or consultation to an MD/DO on the medical staff.) Order radiographic and nuclear medicine studies in order to evaluate musculoskeletal pain or disability on inpatients and outpatients. (Abnormal results that are out of the realm of a chiropractor require referral or consultation to an MD/DO on the medical staff.) Prescribe physical and occupational therapy for inpatients and outpatients. A chiropractor who wishes to use physical therapy equipment or space may do so only after first clearing such use with the director of physical therapy and in consultation, as necessary, with the chief of the medical staff. A supplement to Briefings on Credentialing 781/639-1872 03/07 9

Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s quality assurance mechanisms. Applicants also must be able to demonstrate that they have maintained competence by showing evidence that they have met the continued competence requirements established by the state licensing authority, applicable to the functions that they seek to provide at the hospital. In addition, continuing education related to chiropractic should be required. I understand that, by making this request, I am bound by the applicable bylaws or policies of the hospital and hereby stipulate that I meet the minimum threshold criteria for this request. Physician s signature: Typed or printed name: Date: 10 A supplement to Briefings on Credentialing 781/639-1872 03/07

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Editorial Advisory Board Clinical Privilege White Papers Group Publisher: Bob Croce, bcroce@hcpro.com Managing Editor: Margot Suydam, msuydam@hcpro.com 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 Beverly Pybus Senior Consultant The Greeley Company a division of HCPro, Inc. Marblehead, MA Richard Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Marblehead, 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 2007 HCPro, Inc., Marblehead, MA 01945. 12 A supplement to Briefings on Credentialing 781/639-1872 03/07