Allied Health Professionals/Non-Physician Practitioners

Question 1

The Joint Commission (TJC)
Allied Health Prof/Non-Physician Practitioners

Answer 1

The Joint Commission does not use the term “allied health professionals”. TJC refers to “other licensed practitioners”.
1. For staff other than PAs and APRNs: HR Standards require that before providing care, treatment or services, the qualifications and competence of a non-employee individual, brought into the hospital by a licensed practitioner are assessed by the hospital and are determined to be commensurate with the qualifications and competence required if the individual were to be employed by the hospital to perform the same or similar services.
2. The organization reviews the qualifications, performance, and competence of each non-employee individual brought into the organization by a licensed practitioner to provide care, treatment, or services at the same frequency as individuals employed by the organization
For PAs and APRNs
1. All PAs and APRNs who are providing medical level care (making medical diagnosis and treatment decisions) are credentialed, privileged, and re-privileged through the medical staff process
2. PAs and APRNs who are not providing medical level care can be credentialed, privileged, and re-privileged through the medical staff process or an equivalent process that has been approved by the governing body.
3. An equivalent process at minimum includes: evaluating applicants credentials, current competence, peer recommendations, and involves communication with and input from individuals and committees, including the MEC, in order to make an informed decision regarding the applicants request for privileges

Question 2

National Committee for Quality Assurance with CVO (NCQA)
Allied Health Prof/Non-Physician Practitioners

Answer 2

Non-physician practitioners who have an independent relationship with the organization and provide care under the organizations medical benefits must be credentialed
(CR1, Factor 1)

Question 3

Accreditation Commission for Health Care (ACHC)
Acute Care Hospitals
Allied Health Prof/Non-Physician Practitioners

Answer 3

HFAP standards do not refer to “allied health professionals”. They use the term “non-physician practitioners”.
Standards regarding non-physician practitioners are a direct quote of CMS 42 CFR 482.22(a) and 482.12. The following additional comments are included:
1. The governing boy must ensure that any privileges granted to non-physician practitioners are in accordance with the State law, regulations, and scope of practice.
2. Medical Staff Rules delineate the “qualification” process for non-physician first assistant
3. The Credentials Committee (function) is responsible for credentialing the medical staff as well as non-physician practitioners who provide medical level of care, as applicable
(CMS 42 CFR 482.22(a) and 482.12)
4. For Nurse Practitioners and Physician Assistants, a collaborative agreement or supervisory agreement is required, per State regulations, with a physician who holds the same privileges being requested.

Question 4

Det Norske Veritas (DNV)
Allied Health Prof/Non-Physician Practitioners

Answer 4

MS.2 SR.4 There shall be established policies and procedures approved by the medical staff and governing body for non-physician clinical activities including:
1. Specific type of clinical activities that each class of practitioner will be eligible to perform, consistent with scope of practice under State law
2. Oversight process by the medical staff over each class of practitioner
3. Physician supervision or collaboration, as defined by the hospital and in accordance with State law
4. Process and criteria for reviewing qualifications or each individual practitioner before they are permitted to provide patient care
5. The process, criteria, and frequency for evaluating the performance in providing clinical services by practitioners other than physicians

SRE.5a The medical staff process for examination of credentials and governing body review & approval shall also be extended to non-physician practitioners and licensed healthcare professionals who are applying for clinical privileges but are not eligible for membership

Non-Physicians practitioners my include NPs, PAs, CNSs, CRNAs, CNMs, CSW, Clinical Psychologists, anesthesiologist assistants, RDs/nutrition specialists
All patient care is provided by or in the accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges
For non-physician practitioners granted privileges only, the hospital’s governing body and its medical staff shall exercise oversight, such as through credentialing and competency review, of those practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff

Question 5

Utilization Review Accreditation Commission (URAC)
Allied Health Prof/Non-Physician Practitioners

Answer 5

1. All practitioners who are participating providers and who provide covered health care services to consumers and those who appear in the organizations provider directory are credentialed.
2. The organization verifies the qualifications of all AHPs that may provide clinical services to consumers through a written agreement with the organization.

Question 6

Accreditation Association of Ambulatory Health Care (AAAHC)
Allied Health Prof/Non-Physician Practitioners

Answer 6

The medical/dental staff includes all credentialed and privileged health care professionals, including physicians and AHPs.
1. AHPs include, but are not limited to advanced practice registered nurses and physician assistants.
2. If allowed by the organization, the board must provide a process for the initial appointment, reappointment, assignment or curtailment of privileges for AHPs
3. Accredited organizations may wish to include additional categories of health care professionals (dental assistants and orthopedics technicians) who are employed by a credentialed dentist or physician and assist in surgical procedures

Question 7

Medicare Hospital Conditions of Participation (CoPs)
Allied Health Prof/Non-Physician Practitioners

Answer 7

Interpretive Guidelines (482.12(a)(1) and 482.22(a)
1. The governing body must determine, in accordance with State law, which categories of practitioners are eligible for appointment to the medical staff.
2. The governing body has the authority, in accordance with State law, to grant medical staff privileges and membership to non-physician practitioners.
3. The corresponding regulation at 42 CFR 482.22(a) allows hospitals and their medical staffs to take advantage of the expertise and skills of all types of practitioners who practice at the hospital when making decisions concerning medical staff privileges and membership.
4. Granting medical staff privileges and membership to non-physician practitioners is an option available to the governing body; it is not a requirement3
5. for non-physician practitioners granted privileges only, the hospital’s governing body and its medical staff must exercise oversight, such as credentialing and competency review, of those non-physicians practitioners appointed to its medical staff. Practitioners are described in Section 184(b)(18)(C) of the Act as any of the following
a. PA/NP (as defined in Section 1861(aa)(5) of the Act)
b. Clinical Nurse Specialist (as defined in Section 1861(aa)(5) of the Act)
c. CRNA (as defined in Section 1861(bb)(2) of the Act)
d. NMW (as defined in Section 1861(gg)(2) of the Act)
e. CSW (as defined in Section 1861(hh)(1) of the Act
f. Clinical Psychologist (as defined in 42 CFR 410.71 for purposes of Section 1861(ii) of the Act
g. Anesthesiologist assistant (as defined at 410.69)
h. RD/nutrition professional???

6. Other types of licensed healthcare professionals have a more limited scope of practice and usually are not eligible for hospital medical staff privileges, unless their permitted scope of practice in their State makes them more comparable to the above listed types of non-physician practitioners.
   a. some examples of types of such licensed healthcare professionals who might be eligible for medical staff privileges, depending on State law and medical staff bylaws, rules, and regulations include, but are not limited to: physical therapists (410.60 and 484.4, occupational therapists, speech language therapist
7. Further more, some States have established a scope of practice for certain licensed pharmacists who are permitted to provider patient care services that make them more like the above types of non-physician practitioners including the monitoring and assessing of patients and ordering medications and lab tests.
   a. in such states, a hospital may grant medical staff privileges to scuh pharmacist and/or appoint them as members of the medical staff.
   b. there is no standard term for such pharmacist, sometimes called clinical pharmacist