The opportunity to be credentialed as full members of a hospital medical staff, with admitting, discharge, and appropriate clinical privileges, is essential to practice for many advanced practice registered nurses (APRNs). Unfortunately, in many communities, APRN practice is severely restricted by hospitals’ unwillingness to credential and privilege APRNs. The American Nurses Association (ANA) has a multi-pronged strategy to address this barrier and ensure that APRNs can obtain appropriate clinical privileges.
Having clinical privileges allows APRNs authorization to provide specific care or treatment in a particular setting. Privileges are granted by the appropriate authority, which may be human resources or the medical staff and — according to The Joint Commission definition — are based on license, education, training, experience, competence, health status, and judgment. Credentialing, as defined by The Joint Commission (JC), is “the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization.”
Just as there are similarities and differences in the practice of the four APRN roles, there are variations with regard to their clinical privileging and credentialing. Many acute care nurse practitioners (NPs) and clinical nurse specialists work full time in hospital settings and must be appropriately credentialed and privileged to work to the full extent of their education and preparation. But even NPs who practice primarily in office or ambulatory care settings often need clinical privileges to round on hospitalized patients and provide critical care coordination. Certified registered nurse anesthetists practicing in traditional hospital surgical suites, obstetrical delivery rooms, and critical access hospitals all require some form of clinical practice privileges. For certified nurse-midwives and certified midwives, the ability to admit and discharge patients is a particularly important component of their ability to provide full-scope midwifery care.
In the fall, the regulatory aspect of ANA’s strategy became a priority when the Centers for Medicare and Medicaid Services (CMS) published a proposed rule for Medicare Conditions of Participation (CoPs). CoPs are detailed guidelines hospitals must follow to participate in Medicare and Medicaid, designed to protect patient health and safety, and ensure quality of care. They serve as compliance guidelines for state surveyors and minimum standards for The JC and other private accrediting bodies. While many provisions of the rule are important to nursing (for example, those concerning standing orders), the provision most important to APRNs is the medical staff provision. ANA submitted comments that strongly urge CMS to require hospitals to include practitioners other than physicians on their medical staffs, and to ensure that the process of seeking clinical privileges is uniform, transparent, and timely. ANA strongly encouraged members to provide individual comments to CMS, as well, prior to the Dec. 23, 2011, deadline. ANA’s letter and additional information is at www.nursingworld.org/conditionsofparticipation.
CoPs serve as minimum standards for JC. Many aspects of credentialing and privileging that APRNs are familiar with (including the definition and role of a licensed independent provider, or LIP, and requirements for peer recommendation and for ongoing professional practice evaluation) are more detailed than CMS requirements and are spelled out in the JC “Comprehensive Accreditation Manual for Hospitals” (CAMH). ANA works with its representatives to various JC bodies to address barriers to credentialing and privileging APRNs in JC-accredited institutions.
APRNs who work in a hospital accredited through the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program® may be familiar with a requirement that “the CNO or his or her designee participates in credentialing, privileging, and evaluating advanced-practice nurses.” Those programs must indicate the frequency of re-privileging for Magnet certification, as well. Just as there are a variety of mechanisms for credentialing and privileging APRNs, there are a variety of ways in which CNOs participate in the credentialing process at Magnet hospitals. This organizational overview item does not preclude any particular mechanism for credentialing APRNs.
ANA has collaborated with the American College of Nurse-Midwives on a legislative strategy as well. Although the appetite for significant legislative action in the 112th Congress is unclear, legislation has been developed and there are ongoing discussions with select Hill offices. At this point, ANA awaits the final rule on the CoP changes.
Through this multi-pronged strategy, ANA is working to ensure that APRNs can obtain the clinical practice privileges they need to provide the quality, cost-effective care that patients need and deserve.
— Lisa Summers is a senior policy fellow at ANA.