OO11 A description of the process by which the CNO (or his or her designee) participates in credentialing, privileging, and evaluating advanced practice registered nurses (APRNs). Include the frequency of reprivileging.
OO11 01 HH-400-6030-840 Allied Health Professionals Policy
Advanced Registered Nurse Practitioner (ARNP) means any person licensed in the State of Florida to practice professional nursing and certified in advanced or specialized nursing practice. Chief Nursing Officer (CNO) and Vice President (VP) Gail Gordon, RN, participates in the review of the qualifications, competency and professional conduct of advanced practice registered nurses (ARNPs) in Homestead Hospital.
Current Employment of ARNPs
As of the time of writing, ARNPS are employed by private physician practices and not by Homeastead Hospital. Nevertheless, CNO Gordon participates in the ARNP credentialing, privileging, and evaluation processes. Her involvement promotes patient safety by ensuring that privileges applied for are in accordance with hospital policy and procedure and scope of practice.
Credentialing
In order to be credentialed, ARNPs must complete an Allied Health Professional (AHP) application form from the Baptist Health South Florida (BHSF) Credentialing Verification Services (CVS) office and meet eligibility criteria and qualifications. Verification procedures will be carried out by the BHSF CVS and Medical Staff Services (MSS) will review for completeness in accordance with the procedures defined in the Medical Staff By-laws, Credentials Procedure Manual and Rules & Regulations. After the packet is reviewed by MSS, the application is forwarded, with a recommendation, to the CNO for further review. If the CNO does not endorse the application because she wants Additional Documentation, MSS will obtain the missing information. If she still has reservations about the application at this point, then there would be discussions among the CNO, AHP committee chairperson, and Service Chiefs. If a decision not to proceed is arrived at, MSS contacts the applicant.
The steps outlined in the Medical Staff By-laws and Credentials Procedure Manual are applicable to the credentialing process for AHPs except that all Category II applications (applications that raise some concerns as identified in the criteria) are reviewed by a representative of the Allied Health Professionals Committee prior to review by the Clinical Service Chief, and the Credentials Committee. This variation in process applies to both the initial appointment and reappointment. If after the application review, the CNO, AHP committee chairperson and service chiefs recommend approval, the application is presented to the Credentials Committee and Medical Executive Committee (MEC) for their recommendation to the Board of Directors for final approval
Privileging
Clinical Privileges means the permission granted to an AHP to render specific patient services. Privileges are based on the AHPs’ licensure, education, training, experience, and demonstrated current competence, as well as the limitations defined by the hospital for operational or risk management reasons. ARNPs must have a designated supervising physician, acceptable to the medical staff. The primary supervising physician must hold clinical privileges in good standing. There will be a copy of the Supervising Physician’s Agreement submitted with the ARNP application. The Supervising Physician’s Agreement it is to be signed by all of the physicians that will be supervising the ARNP, or if a group the head of the group may sign for all the supervising physicians. The primary supervising physician must sign the privileges of the supervised ARNP, in which he/she accepts responsibility for appropriate supervision of the services provided by each ARNP under his/her supervision and agrees that the ARNP will not exceed the scope of practice as defined by the privileges granted and by law. The CNO is a non-voting member of the Credentials Committee. However, she or a designee attends the monthly meetings especially when it involves an AHP credentialing application to provide input and ensure that she is in agreement with the privileges being requested. Once the credentialing process is completed the ARNP is deemed able to have clinical privileges. If the ARNP begins employment prior to completion of the credentialing process, the ARNP cannot exercise the requested clinical privileges (including functioning under standardized protocols/procedures) until the credentialing process has been successfully completed.
Reappointment
All ARNP’s are presented for reappointment to the Credentials Committee, MEC and the Board every 2 years. Reappointment procedures as defined in the Medical Staff By-Laws, Credentials Procedure Manual are followed for all AHPs. This includes data that is gathered for all credentialed medical staff members and AHPs, as applicable to the services provided and available data. During the reappointment process, the Clinical Service Chief/designee is permitted access to pertinent performance evaluations.
To ensure that the hospital fulfills equitable expectations for all privileged AHPs, the following documents will be required annually by all privileged AHPs:
- Supplemental Health Information Form (gathered and monitored by the CVS)
- Completion of Annual Required BHSF Education
After the packet is reviewed the application is forwarded, with a recommendation, to the CNO for further review. The application undergoes the same review and approval process as described above in the Credentialing and Privileging sections.
Evaluation of Performance
The performance of all AHPs will be evaluated as part of the medical staff’s routine performance improvement processes. Therefore, the ARNP’s performance will be evaluated, as applicable, and consistent with the medical staff policies and procedures regarding focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE). ARNPs must have a designated supervising practitioner, approved by the Credentials Committee, the MEC and the Board. The primary supervising practitioner must agree to participate as requested in the evaluation of competency (i.e., during and at the conclusion of the initial FPPE; at the time of reappointment; whenever new or additional privileges have been requested; and during remediation, as indicated) of the supervised ARNP(s) through a letter attesting to direction observation of AHP competency. The primary supervising practitioner is not solely responsible in the evaluation of competency. Physicians other than this individual may be included in the evaluation of competency and input from the CNO/VP and others as appropriate is also solicited. Any concerns regarding the quality or appropriateness of care provided by an ARNP identified during such review processes shall be referred to an appropriate Medical Staff Quality Committee (MSQC). Any concerns regarding the supervision of an ARNP by a physician shall be referred to MSQC or Professional Review Committee (PRC).
Allied Health Professionals (AHP) Committee
The AHP Committee is a committee of the MEC. The Chairperson is appointed by the President of the Medical Staff. It is comprised of AHPs and other members deemed appropriate by the Chairman for a two year term. Such appointments may include AHPs, the CNO or designee and any others as deemed appropriate. The CNO attends the AHP Committee meetings. The duties of the committee include:
- Evaluating and making recommendations to the MEC and the Board regarding the need for services that could be provided by classes of AHPs that are not currently permitted to practice in the hospital.
- Developing and recommending policies and privileges for each class of AHP permitted by the Board to practice in the Hospital, including policies and privileges related to training, education and experience, which AHPs must have to be granted a scope of practice within the hospital.
MSQC
MSQC is responsible for evaluating and improving physician and Allied Health professional performance in the areas of clinical quality, physician/AHP responsiveness, documentation issues and clinical resource use related to physician/AHP patterns and retrospective review of unusual or complex specific cases. An ARNP from the AHP Committee is a member of MSQC.
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