Hospitals have traditionally credentialed and privileged, through the medical staff process,

all allied health professionals (AHPs) who are employed or supervised by the medical staff.

Now, The Joint Commission has defined an explicit group of practitioners, such as PAs, NPs,

CRNAs, and nurse midwives, who must continue to be credentialed and privileged, while

the rest must have their competence assessed in a manner equal to hospital employees.

The Joint Commission requirements regarding licensed independent practitioners (LIPs) who

bring their employees into the organization are at the crux of the AHP conundrum. These

dependent healthcare professionals often provide the same services as employees of the

organization, and must be authorized and have their competency assessed in an equivalent

manner. But does the MSO know the HR standards for compliance?

MSPs may do all the work to credential these practitioners, yet still fail to meet the Joint

Commission’s new standards to ensure that practitioners brought into the hospital through

LIPs are assessed at a level commensurate to those individuals employed by the hospital.

Using this book and CD-ROM set, discover how your organization can best authorize

non-credentialed practitioners and achieve compliance. You’ll learn how to:

• Identify which individuals belong in the medical staff privileging process and

which should be transitioned to the HR authorization process

• Develop nomenclature for the organization that is more descriptive than the

terminology used today

• Redesign current methods using a simple 6-step process

• Develop and implement a transition plan that is efficient and manageable for

both the MSO and HR

• Ensure that safety and quality of care are upheld when your hospital chooses

to transition practitioner authorization to HR

|200 Hoods Lane | Marblehead, MA 01945

www.hcmarketplace.com

SAHPC

Solvin

g the A

HP

Conundru

mCAIRNS

Carol S. Cairns, CPMSM, CPCS

Solvingthe AHPConundrumHow to Comply with HR Standards Related toNonprivilegedPractitioners

Solving the AHP

ConundrumHow to Comply with

HR Standards Related to Nonprivileged Practitioners

SAHPC-Cvr r1.qxp 8/20/07 3:14 PM Page 1

About the author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix

Step 1: Recognizing changes in healthcare that affect AHP credentialing . . . . . . . . . . . .1

Step 2: Setting a course for credentialing AHPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Step 3: Establishing terminology and definitions

for privileged vs. nonprivileged AHPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Step 4: Understanding The Joint Commission HR standards’ effect on

nonprivileged AHPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Step 5: Designing a new approach to credentialing nonprivileged AHPs . . . . . . . . . . . .59

Step 6: Transitioning to the HR process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83

Appendix A: Case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91

Mercy Medical Center; Nampa, ID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91Figure A1.1: AHP credentialing process flow chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95

Figure A1.2: AHP decision grid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

Figure A1.3: Position description, private nonphysician surgical first assistant . . . . . . . . . . . . . . . . . .97

Figure A1.4: Position description for a dental/oral surgery assistant . . . . . . . . . . . . . . . . . . . . . . . . .103

Figure A1.5: Worksheet for developing criteria for dental assistants . . . . . . . . . . . . . . . . . . . . . . . .108

Figure A1.6: AHP performance evaluation form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Contents

SOLVING THE AHP CONUNDRUM © 2007 HCPRO, INC. iii

Hillcrest Medical Center; Tulsa, OK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115Figure A2.1: Draft policy and procedure for use of AHPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118

Yakima (WA) Regional Medical & Cardiac Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123Figure A3.1: AHP-limited perfusionist job description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126

Appendix B: Contributions from the field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135

St. John’s Hospital; Springfield, MO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137Figure B.1: Administrative policy for dependent AHPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138

Figure B.2: AHP application for clinical privileges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

XYX Medical Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169Figure B.3: Flow chart showing process for transitioning AHPs to HR . . . . . . . . . . . . . . . . . . . . . . .170

Figure B.4: AHP annual clinical evaluation form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171

Forrest General Hospital; Hattiesburg, MS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177Figure B.5: Scope of practice for dependent AHPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179

Figure B.6: Supervising physician statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181

Figure B.7: Dependent AHP annual performance evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182

Figures B.8–B.21: Position descriptions for 14 AHP disciplines . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183

Appendix C: Job descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .211Figure C.1: List of job descriptions on accompanying CD-ROM . . . . . . . . . . . . . . . . . . . . . . . . . . .212

Example Surgical Technician Job Description and Performance Standards . . . . . . . . . . . . . . . . . . . .214

© 2007 HCPRO, INC. SOLVING THE AHP CONUNDRUM

Contents

iv

Recognizing changes inhealthcare that affect

AHP credentialing

Before an organization can focus on credentialing allied health practitioners (AHP) who do

not require privileging via the medical staff, it is essential to have a broad understanding of

the issues related to the allied health disciplines.

Understanding important changes in healthcare will help organizations chart future courses for

credentialing AHPs. In fact, these developments—such as variations in state licensure and the

broadening scope of healthcare services—push organizations to confront the issue of creden-

tialing AHPs.

Unlike physicians or dentists—whose scopes of practice have been defined over time and are

therefore clearly understood by licensing and regulatory authorities, by institutions that cre-

dential and privilege them, and by patients—AHPs’ scopes of practice are not clearly defined

and thus are not always understood. For example, the state licensure for physicians is fairly

uniform across the 50 states. Regulatory agencies such as The Joint Commission and the

National Committee for Quality Assurance (NCQA) clearly identify healthcare entities’ responsi-

bilities to credential and/or privilege physicians. Likewise, patients generally understand the

SOLVING THE AHP CONUNDRUM © 2007 HCPRO, INC. 1

1STEP

2

ST E P 1

© 2007 HCPRO, INC. SOLVING THE AHP CONUNDRUM

scope of practice of their physicians—whether they are primary care practitioners or specialists.

However, the allied health disciplines do not share this clarity of scope of practice.

State statutes vary

One important area in healthcare undergoing change is states’ individual treatment of AHPs. As

states develop their own statutes (licensures) related to AHPs, they have created a varied and

uneven landscape with regard to whether the advanced practice allied health disciplines may

practice independently. In one state, a nurse practitioner (NP) may be considered an independ-

ent practitioner with the authority to practice completely independently of a physician—he or

she could have an independent office practice and have full authority to prescribe medication

by state licensure. In another state, the same NP may be required to have a collaborating or

supervisory agreement with a physician and may or may not have prescriptive authority.

In the case of a massage therapist or an acupuncturist, one state may license or register either

individual, while another state may not, thus leaving healthcare organizations to rely on certifi-

cation as a possible criterion for credentialing. And as with the NP, the scope of services that

states may authorize for a particular individual is not consistent across the nation—for example,

the acupuncturist may be allowed greater latitude in providing patient care independently in

one state than in another.

This lack of uniformity among state licensure and the continuously evolving licensing statutes

that apply to the allied health disciplines pose problems for healthcare entities as well as AHPs.

For example, a physician assistant (PA) who has been licensed (authorized) in state A to pre-

scribe medications, including controlled substances, may move to state B, which does not per-

mit PAs to prescribe a narcotic medication. If the PA orders a controlled substance for a hospi-

talized patient in state B, the PA is functioning beyond the scope of his or her license. Further,

the PA’s physician supervisor, medical staff, and governing body in state B are also at risk for

allowing this practice to occur. Although the licensure laws of each state generally are clear, this

circumstance happens easily and often as practitioners move from state to state. As more profes-

sional organizations seek recognition of AHP professions, licensing bodies will be under increas-

ing pressure to recognize and authorize the services that these individuals provide.

Additional confusion is created by varied wording within state statutes regarding AHPs’ eligibility

for membership on hospital medical staffs. Hospital licensing regulations in some states clearly

3

Recognizing changes in healthcare that affect AHP credentialing

SOLVING THE AHP CONUNDRUM © 2007 HCPRO, INC.

define which medical disciplines are eligible to be members of the medical staff. For example,

state A’s statute may provide that “physicians, dentists, and podiatrists are eligible for member-

ship to the hospital medical staff,” whereas state B’s statute leaves the option to the hospital by

stating that “the healthcare organization will determine the healthcare disciplines that are eligi-

ble for membership.”

Still other states, such as Ohio, may require that if an organization chooses to provide services

from a particular discipline—such as psychology or podiatry—then an individual practicing in

that discipline must be eligible for membership on the medical staff or for professional privi-

leges. In this instance, if an organization is contemplating offering podiatric or psychological

services, the medical staff bylaws must also provide the individual access to medical staff mem-

bership or clinical privileges. Ohio regulations also stipulate that if the organization provides

maternity services, in considering and acting on requests, it shall not discriminate against a

qualified person solely on the basis that the individual is authorized to practice nurse midwifery

and not obstetrics.

Adding another layer, some states are very protective of the AHP’s right to practice. For exam-

ple, in New York, healthcare organizations may not discriminate against a chiropractor who

wishes to order and receive the results of diagnostic radiology testing. However, other state

statutes authorize the use of radiological modalities by chiropractors but restrict such use to

specified parts of the body. In such situations, the healthcare organization must consider its

state’s imposed limitation when considering any chiropractic request.

Another example of varied state regulations: Statutes in California, Hawaii, and Wisconsin

expressly allow psychologists hospital admitting privileges, and statutes in Mississippi and

Montana specifically state that psychologists are allowed joint admitting privileges; and there are

many more states that do not allow psychologists to admit to a hospital. Thus, when consider-

ing psychologists’ eligibility to admit or co-admit, hospitals should base their decisions on state

law as well as on the clinician’s training and experience.

Yet another example of the range of permissiveness of state licensing agencies is in prescriptive

authority. For example, the vast majority of states do not allow psychologists to prescribe.

However, in 2002, New Mexico became the first state to permit psychologists to use this clinical

authority. In May 2004, Louisiana did so as well, provided that the psychologist has completed

certain defined postgraduate education in psychopharmacology and passed an examination. The

Louisiana law also requires the psychologist to work collaboratively with the patient’s physician

4

ST E P 1

© 2007 HCPRO, INC. SOLVING THE AHP CONUNDRUM

when prescribing medication. The scope of the prescriptive authority is limited to medications

for nervous and mental health disorders.

The importance of identifying applicable state statutes for all AHPs cannot be overemphasized

and will be reiterated throughout this book. It is paramount that organizations understand the

difference between what scope of practice is permitted by the state licensing organization and

what scope of practice will be permitted by the healthcare facility.

AHPs’ scopes of practice

A second important area that has changed in healthcare is AHPs’ scopes of practice. Due to

physician shortages, the education and training of many AHPs has intensified, especially in

underserved areas. Physicians often seek out higher levels of education and training for their

AHP support staff and mentor these colleagues to enhance their understanding of the clinical

conditions being diagnosed and treated. Physicians are also teaching AHPs to perform proce-

dures that historically have been performed only by physicians—and physicians expect hospitals

to privilege the AHP for these procedures.

The need for hospitals, managed care organizations (MCO), and physicians to contain or

decrease healthcare costs is another incentive to encourage AHPs to seek advanced training. By

using AHPs as “physician extenders,” physicians can become more efficient by focusing their

efforts on those responsibilities that require the level of knowledge and expertise gained

through medical school and residency training.

Patients benefit by AHPs’ increased expertise in a more narrow area of clinical practice. For

example, physicians often employ nurse educators to assist in patient education during the diag-

nosis, treatment, and postoperative phases of care. These nurses are well-trained in the specific

clinical issues related to diagnoses and surgical procedures (e.g., nutrition, appropriateness and

timing of exercise, wound care, management of complications or outcomes, use of prosthetics,

etc.). Further, patients frequently report that nurses take extra time with them and are often

more available for follow-up questions than are physicians.

As AHPs’ levels of knowledge, training, and experience increase, these individuals and AHP pro-

fessional organizations seek recognition for their enhanced abilities—comparable to the process

that physicians have sought in specialty and subspecialty board certification and certificates of

5

Recognizing changes in healthcare that affect AHP credentialing

SOLVING THE AHP CONUNDRUM © 2007 HCPRO, INC.

added qualifications. In fact, over the past 10 years, at both the state and federal levels, many

pieces of legislation have been introduced that propose:

• Expanding AHPs’ scopes of practice

• Extending the level of AHPs’ clinical independence

• Entitling more categories of AHPs to direct reimbursement

Some of these efforts were successful. For example, in West Virginia, NPs won the right to be

considered primary care practitioners within health maintenance organizations. Optometrists

were able to expand their authority to prescribe diagnostic and therapeutic pharmaceuticals in

several states. In Virginia, physical therapists now have the authority to see patients without the

need for a physician order, and several other states are also considering this option.

Early on, Florida, Georgia, Kentucky, Maine, Minnesota, Rhode Island, West Virginia, and

Washington legislated the right of registered nurse first assistants to direct reimbursement. As of

this writing, several more states have approved or were considering similar legislation.

There is, of course, continuing controversy over the level of independence of the certified regis-

tered nurse anesthetist (CRNA). Until the end of 2001, the Centers for Medicare & Medicaid

Services required physicians to supervise CRNAs. However, a rule published in the November

13, 2001, Federal Register gave state governors the authority to allow CRNAs to administer anes-

thesia care to Medicare patients without physician supervision. So far at least 12 states have

opted out, thus exempting CRNAs from physician supervision.

Services provided by healthcare organizations

The changing services provided by healthcare organizations have also affected AHP credential-

ing. In the past, hospital care was clearly defined: Acute care was provided in a two- to nine-

story building clearly identified as a hospital; hospitals had no interest in expanding to ambula-

tory sites or extending into community settings.

Yet nothing escapes change. Here are just some of the ways that healthcare organizations’ serv-

ices have radically evolved:

• Enhanced diagnostic tools

6

ST E P 1

© 2007 HCPRO, INC. SOLVING THE AHP CONUNDRUM

• Expanded technology, allowing for ultrasonic, computer-assisted, or endoscopic

approaches for diagnostic and therapeutic purposes

• Emphasis on decreasing the use of invasive procedures and increasing the use of

pharmacological agents

• Increased importance and education regarding health and fitness measures

• Decreased reimbursement for services rendered

These changes have prompted additional use of AHPs in a variety of settings that are no longer

solely within the domain of the acute care facility. Increasing numbers of AHPs—including chiro-

practors, massage therapists, independent NPs, social workers, and nutritionists—are approaching

healthcare organizations, seeking approval to provide services within that setting.

Regulatory compliance

Another key area of change within healthcare is the evolution of regulatory standards. Prior to

the advent of managed care, generally only hospitals were required to credential and privilege.

But the arrival of MCOs created a need to develop standards of excellence for the managed care

industry. In 1990, the NCQA became independent of its parent organization, the Group Health

Association of America, and now represents the interests of consumers and healthcare organiza-

tions.

The NCQA has developed credentialing standards for MCOs, managed behavioral healthcare

organizations, physician organizations, preferred provider organizations, and credentials verifica-

tion organizations for the credentialing and recredentialing of licensed independent practitioners

(LIP) with whom organizations contract or employ, and who fall within its scope of authority and

action. Thus, the NCQA’s minimum expectation is that the MCO will credential physicians, den-

tists, podiatrists, chiropractors, various behavioral health practitioners, and practitioners who

would provide care to patients as a primary care practitioner. These standards do not apply to

the AHP disciplines that are the focus of this book.

The Joint Commission is another regulatory body that directs the credentialing of AHPs. In the

past, The Joint Commission devoted an entire chapter to specific requirements for the credential-

ing and privileging of AHPs in the Comprehensive Accreditation Manual for Hospitals (CAMH).

However, this chapter no longer exists. The current medical staff standards delineated in the

7

Recognizing changes in healthcare that affect AHP credentialing

SOLVING THE AHP CONUNDRUM © 2007 HCPRO, INC.

CAMH do not specifically address AHP credentialing, although they do reference LIPs who are

permitted to function independently by the state and by the organization.

The Overview of the Medical Staff Standards chapter of the CAMH and one standard in the

Human Resources chapter address the credentialing and privileging of advanced practice nurses

and PAs (see Step 2 of this book). The Joint Commission has outlined new regulations for

physician-employed or -sponsored AHPs who do not require privileging but do require equiva-

lent competence to an employee. (The current Joint Commission requirements related to cre-

dentialing nonprivileged AHPs are found in Step 4 of this book.) Therefore, healthcare organiza-

tions must be knowledgeable of these requirements to make the right choices regarding the

routes and methods of processing AHPs.

Public awareness and demand

The fifth area of change is the effect of public awareness and demand on healthcare organiza-

tions. Patients increasingly request that healthcare entities provide additional services such as

midwifery, acupuncture, marital counseling, drug and alcohol rehabilitation therapy, massage

therapy, and relaxation techniques (e.g., biofeedback, imagery, and hypnotherapy). Expanding

patient awareness and demand—especially in the complementary and alternative medicine

arena—has become another challenging issue for organizations’ medical and administrative

leadership.

Fear of antitrust

The sixth change affecting the role of AHPs is healthcare organizations’ fear of being accused of

excluding a discipline and therefore inviting charges of antitrust activity. A variety of allied

health disciplines have brought suit against professional associations, states, and hospitals, alleg-

ing antitrust activities.

As noted in the beginning of Step 1, it is important to reflect upon not only what has changed

but also on what is changing to determine future courses of action. Understanding these

changes will help organizations determine opportunities for redesigning their credentialing

routes and methodologies.

Name

Title

Organization

Street Address

City State ZIP

Telephone Fax

E-mail Address

Order your copy today!

Title Price Order Code Quantity Total

$

Shipping* $ (see information below)

Sales Tax** $ (see information below)

Grand Total $

*Shipping InformationPlease include applicable shipping. For books under $100, add $10. For books over $100, add $18. For shipping to AK, HI, or PR, add $21.95.

**Tax InformationPlease include applicable sales tax. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV.

State that taxes products only: AZ.

BIllInG OPTIOnS:

Bill me Check enclosed (payable to HCPro, Inc.) Bill my facility with PO # ________________

Bill my (3 one): VISA MasterCard AmEx Discover

Signature Account No. Exp. Date

(Required for authorization) (Your credit card bill will reflect a charge from HCPro, Inc.)

© 2008 HCPro, Inc. HCPro, Inc. is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Code: EBKPDF

Order online at www.hcmarketplace.com Or if you prefer: MAIl ThE COMPlETEd OrdEr fOrM TO: HCPro, Inc. P.O. Box 1168, Marblehead, MA 01945

CAll Our CuSTOMEr SErvICE dEPArTMEnT AT: 800/650-6787

fAx ThE COMPlETEd OrdEr fOrM TO: 800/639-8511

E-MAIl: customerservice@hcpro.com

P.O. Box 1168 | Marblehead, MA 01945 | 800/650-6787 | www.hcmarketplace.com

Please fill in the title, price, order code and quantity, and add applicable shipping

and tax. for price and order code, please visit www.hcmarketplace.com. If you

received a special offer or discount source code, please enter it below.

Your order is fully covered by a 30-day, money-back guarantee.

Enter your special Source Code here: