Keywords

1 Introduction

This chapter will focus on the processes for credentialing, privileging, and maintenance of certification. The advanced care practitioner will be able to understand the differences between credentialing and privileging as well as the importance of each process. The role of state laws, regulatory agencies, and accreditation agencies will be discussed to provide the context of these processes. The chapter will conclude with a discussion on the role of certification and maintenance of certification as it pertains to compliance with regulatory and accrediting agencies, competency , and patient safety.

Before discussing the various processes in this chapter, it is crucial to define them for clarity. Many times the processes of credentialing, privileging, and maintenance of certification are confused or combined into one concept. However, there are three distinct and separate processes that happen to be interrelated as they all apply to patient care and competency.

Credentialing is a formal process that has both internal and external regulatory requirements for reviewing the “credentials” of an applicant for clinical appointment within an institution or practice. This process is governed by internal policy, state law, external regulation , and accreditation requirements. During this process, the candidate’s degrees, medical training, licensure, certifications, professional references, competency attestations, malpractice data, and insurance claims data are reviewed. This process focuses on primary source verification. The medical staff office or practice management will request documentation and will contact information sources directly such as universities, training program, previous employers, national databases, and licensing bodies [1].

Privileging is an internal process used by institutions and practices to define and approve clinical activity. This process is governed by internal policy and is referenced by state law, external regulators, and accreditation agencies. Unlike credentialing, the process for privileging is completely at the discretion of the institution or practice. The external groups merely require that there is a standard process in place and that clinicians are deemed to be competent, but they do not define what that process entails. A clinician’s privileges define their scope of practice, detail the specific patient care activities that are allowed, and communicate to other members of the workforce what each provider is allowed to do within the institution or practice [2].

Maintenance of certification (MOC ) is a process in which individual clinicians complete certain training, education, performance improvement, and self-assessment activities in order to keep certification from state or national certification agencies. This typically includes a formal examination of medical knowledge, patient care, ethics, and regulatory knowledge. The MOC process varies by each certifying agency and is typically specific to physicians, advanced practice registered nurses, and physician assistants. State and government licensing agencies typically require these profession-specific certifications for the granting of licensure. There are also certifications that are not specific to any profession such as radiation safety certification, CPR, fundamentals of critical care, pediatric advanced life support, and others. These types of certifications may be required by institutions and practices in addition to the professional certifications that are required to keep licensure. MOC is usually a requirement for continued credentialing and the grant of privileges by institutions and practices.

It is evident that these processes are interrelated, but it is also important to remember that each process has its own requirements, timeline, and review process. In general institutions and practices use these processes to fulfill both internal and external requirements to ensure that clinicians are competent, that patients are treated safely, and that quality care is provided. Accrediting agencies such as the Joint Commission require that certain elements of performance are completed during credentialing and privileging in order for an institution or practice to be accredited. Government agencies such as the Centers for Medicare and Medicaid Services (CMS) and insurance companies also require that certain conditions of participation are met before they will reimburse for patient care and other clinical services [3]. It is crucial that clinicians have an understanding of these processes and comply with requests for information, documentation, and professional references, as well as meet any training or education requirements as indicated by the institution or practice.

2 Credentialing

This is the first step to practice as an Advanced Care Practitioners (ACP ) . Any employer will need to review the education, training, certification, and previous work experience of an ACP [4]. Small practices and large institutions are required to complete this assessment at a minimum to ensure patient safety. Institutions such as hospitals and university medical centers will have a well-defined process in place that will likely be governed by bylaws and policies. Clinical practice may simply have checklists or internal guidelines. Whichever the case, it is crucial for the ACP to review the process and follow it within the timeframe allotted.

Primary source verification is a key concept within the credentialing process. Employers will go to the source of information that can verify the credentials of the ACP. This will include education, licensure, certification(s), and last employment position. Employers will contact the sources of this information directly without the need for the ACP to provide any additional information [5]. The ACP should not list any items in the credentialing packet that cannot be verified.

The review of Malpractice and Insurance Claims data will be completed at institutions and based on state requirements for reporting by the ACP. There are several national databases that provide this service for a fee. The ACP will not be asked to gather or provide this information from these national databases. However, they may be required to self-report any malpractice history or insurance claims. The ACP should be prepared to discuss each judgment, dismissal, or claim to provide the clinical details and outcomes. It is critical to be completely forthcoming with the details for any/each event. The ACP can face a negative credentialing decision if they mischaracterize or omit any information.

The ACP will be requested to furnish a substantial list of information in the credentialing application beyond education, licensure, certification, and work history. The process will include written attestations of fitness for duty and self-reporting. As previously mentioned, this will include malpractice and insurance claims. This will also include standard questions regarding health status, mental health history, physical disability, substance abuse, rehabilitation from addiction, and behavioral issues. The ACP will also be asked to describe any disciplinary issues from previous employers. While this information may seem intimate and personal, it is required by credentialing processes and based on state law, accrediting agencies, and payer’s requirements for enrolling providers into their system.

Professional references are an important part of the credentialing process that will require careful consideration by the ACP. Identifying those physicians, physician assistants, and advanced practice registered nurses that have recently worked with the ACP in a clinical setting is only one aspect of professional references. It will be crucial for the ACP to ensure that those references are not only familiar with the clinical work of the ACP but can also positively speak to the competence and professionalism of the ACP. Poor feedback from professional references can significantly impact the credentialing process unfavorably.

Once the credentialing application is complete, the review process begins. This will include review by the medical staff office or practice management to ensure that the application is complete. Once the application is complete, it will then be submitted for formal review by a credentials committee that will include review from professional peers. The review process is governed by a number of guidelines that will be based on bylaws and policies as well as outside regulatory agencies [6]. There will also be a process to appeal any decisions if they are negative toward the ACP. It is important for the ACP to review the process and understand all of their options during the process. Negative credentialing decisions are reportable and discoverable. A negative credentialing decision can significantly impact future employment of an ACP.

3 Privileging

This is the process that governs what the clinical role or scope of practice will be for an ACP. Once an employer had accepted the credentials of an ACP, they must define what the role of the ACP will be within their organization. There is typically a standard request form that is completed by the ACP and their collaborating physician(s). This form may have a standard set of clinical activities, procedures, and patient care responsibilities, or it may be up to the ACP to define what they will need to be authorized to do in order to effectively provide patient care. The privileging request is typically reviewed by the same committee that reviews credentialing applications. It is important to remember that the ACP is not authorized to engage in any kind of patient care until they receive privileges [7].

The purpose of privileging is not only to define the clinical role of the ACP; it also ensures that there are minimum standards in training and experience for the ACP to hold each particular privilege. This is one of the most important methods for ensuring patient safety and quality of care. Typically healthcare institutions, practice groups, or hospitals will set parameters around the type of training and a minimum number of times an ACP has performed certain procedures before they will grant authority for the ACP to perform those procedures. There may be required training protocols and standard competency assessments as part of the privileging process. The ACP should maintain a log of their training and the number of each procedure that they have performed. This will greatly simplify the privileging process by providing a detailed account for review.

When an ACP has held privileges at previous institutions, having letters of attestation from supervising physician(s) is in the best interest of the ACP. These letters can be used in lieu of having to recomplete training and perform minimum numbers of procedures. It makes little sense for an ACP to spend time in this activity if they have previously held and competently performed privileges. Even with letters of attestation, some employers may require the ACP to demonstrate proficiency and competency in certain procedural privileges before granting the ACP that privilege. This should not discourage or concern the ACP. They should be willing and able to demonstrate their skill and expertise as needed.

For the advanced practice registered nurse (APRN) , it is important to understand the role of the chief nursing officer (CNO) for any institution. Beyond what is required by the medical staff, bylaws , policy, or practice guidelines, the CNO has the responsibility and authority to govern nursing practice. This may be as simple as reviewing the previous experience, licensure, and certification or the APRN. However, it can include additional documentation, peer references, or specific training required for nurses within the institution such as mock code certification, population-based competency training, or age-specific competency training. The APRN should be aware of the role of the CNO and any additional requirements for clinical practice that might be required.

When applying for privileges, it will be fundamentally important for the ACP to understand the laws of the state that govern their professional practice. Typically, each state will have laws that govern the practice of APRNs and PAs. There is a great deal of variation in ACP practice laws from state to state. The ACP should never assume that what was allowed in one state will also be allowed in another state. The ACP must review the practice laws governing their profession in each and every state in which they practice. State law typically sets the maximum (the “ceiling”) of professional practice for the ACP. Employers are allowed to lower the professional practice of ACPs to less than what the state allows. This could include a requirement for certain orders to have physician co-signature, limitations on independent practice, or limitations on certain procedures or clinical activities. While the ACP may not agree with these limitations, it is important to realize that this kind of limitation is allowable and a normal practice. Fortunately, most employers realize that limiting ACPs is detrimental to clinical effectiveness, patient access, and quality of care.

The privileging process is one that is continuous in nature. Simply because one was granted privileges in the past does not mean that they will continue on indefinitely. National accreditation standards, such as the Joint Commission (JC), require the institutions to review the performance and set minimum standard for the maintenance of privileges. Additionally, it is an accepted practice standard to re-privilege physicians, APRNs, and PAs every two years. During these cycles, the number of times an individual has performed certain procedures and the quality with which they were performed will be reviewed. It is worth mentioning that there are two review processes utilized: Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE). The FPPE process is used when an individual is first granted privileges, receives new privileges, or has questions raised about their competence. During FPPE, the ACP will be assigned a proctor that will be responsible for evaluating the ACP performance. This evaluation will last a minimum of 6 months and can include chart review, interviews, observation, testing, and discussing performance with peers or staff [8]. Once FPPE is successfully completed, the ACP will move into the OPPE process. This requires the ongoing and current review of metrics and data that must be accumulated to assess the ACP performance in comparison to others that hold the same privileges. The purpose of OPPE is to identify outliers in clinical practice with regard to utilization of resources, adherence to practice standards, quality of care, and patient safety [9].

The ACP should review and understand all of the requirements for the privileging process, FPPE, OPPE, and re-privileging. These are typically outlined in bylaws , policies, or practice guidelines. The ACP should engage in conversations with their clinical supervisors and managers early in the process to ensure that they have the support and direction they need to be successful.

4 Maintenance of Certification

The certification process is the mechanism used by local and national professional certification bodies to document that ACPs have met certain standards and in some cases have passed standardized examinations. Some of these certifications, such as the Physician Assistant National Certifying Examination (PANCE ), are requirements for obtaining licensure as an ACP [10]. The initial certifications are typically based on completing education in an ACP training program and then passing a standardized examination. However, maintenance certification generally requires a commitment to ongoing education, clinical practice, performance improvement, self-assessment, and other activities.

Generally speaking, certification is used as a surrogate for competency in the areas of medical knowledge and patient care . There are some certifications that are used to ensure technical competencies and knowledge of safety processes such as Radiation Safety Certification . The point of these certifications is to ensure that ACPs are exposed to a standard set of knowledge and skills related to their work of providing care to patients. As such, institutions, medical practices, licensing boards, accrediting agencies, and insurance companies have adopted these certifications as an indication that an ACP is prepared to provide care and should be reimbursed for that care.

Is it imperative that the ACP is aware of the certifications that are required for their practice and the roles they assume within each institution or practice. Additionally, they must adhere to the prescribed methods set forth by each certifying agency for the maintenance of their certifications. In most cases, this will require the ACP to complete a certain number of continuing education hours within a specified time frame or cycle. Some certifications require specific content such as ethics or pharmacology. Others simply provide general requirements that the continuing education meet certain standards and that a specified number of hours are completed within each certification cycle.

The ACP should be aware of the recent changes in physician maintenance of certification. The American Board of Internal Medicine (ABIM ) , for example, has created a 10-year cycle for physicians in internal medicine specialties that will require a number of areas of activity. These include: continuing education in medical knowledge, practice assessment (performance improvement), patient safety training, and passing a recertifying examination [11]. This is important for the ACP because some certification bodies such as the National Commission on the Certification of Physician Assistants (NCCPA ) have adopted this MOC process. This means that ACPs can and should work with their collaborating physicians in completing MOC activity. This is particularly true for practice assessment in which the care of patients is assessed for adherence to certain standards of care, and then practice improvements are implemented. This type of activity is intended to educate participants in the area of performance improvement.

It is important that the ACP is supported in MOC activity by their institutions or practice. The ACP will need time and funds in order to participate and successfully complete the variety of educational and performance assessment activates required for MOC [12, 13]. It is a generally accepted practice that physicians, advanced practice registered nurses, and physician assistants are granted a certain number of educational days per year and a fixed amount of funding for their MOC. The ACP should discuss these benefits as part of the interview process and before they accept any position.

5 Summary

The ACP must be aware of the processes and requirements involved in credentialing, privileging, and maintenance of certification. As they expand their clinical skill and learn new procedures, these processes will govern their ability to provide care to their patients. Every institution and practice has internal and external requirements to ensure that providers are competent to provide safe and effective care. This also includes insurance companies and other payers that have their own sets of rules that govern who they reimburse for care and how they reimburse that care. The ACP must be informed and adhere to all of these if they wish to be successful in growing their practice, learning new procedures, and providing quality care to their patients.