The Quality Cost Connection: Credential your allied health professionals

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

The medical staff credentialing process serves several purposes. First, the process helps in setting standards for the practice of patient care within the institution to ensure quality patient care. Well-drafted credentialing policies and procedures also can reduce potential legal problems. In years past, only fully licensed physicians were credentialed and privileged through the medical staff. However in recent years a new group of practitioners has emerged — allied health professionals (AHPs). These practitioners are nonphysician health care workers. They may be classified as either independent or dependent practitioners.

An independent practitioner may provide patient care in accordance with state licensure laws and with medical staff oversight, exercise their own judgment, and assume a considerable level of responsibility for patient care. Dependent practitioners only provide patient care under the direct supervision of a sponsoring physician. AHPs may be employed by a physician member of the medical staff or may be independent practitioners with a member of the medical staff serving as their sponsoring physician. These individuals also may be hospital employees.

Regardless of who the AHP reports to, it is important for the hospital to ensure that patients are protected from any unreasonable risk of harm. While some AHPs, by law, must have a supervising physician onsite or available by phone, these nonphysician practitioners make many autonomous medical decisions in everyday practice. Because they provide clinical services and generally exercise a high level of responsibility for patients’ medical care, many hospitals find it prudent to formally credential and recredential AHPs.

The standards of the Joint Commission on Accreditation of Healthcare Organizations do not prohibit hospitals from appointing AHPs to the medical staff and/or credentialing and privileging them. Many hospitals have a special category for these practitioners. The credentialing process does not have to be exactly the same as that used for physicians, although it is important that the process for credentialing AHPs be consistent among the various disciplines. For example, advanced nurse practitioners should be credentialed in the same manner as physician assistants. Credentialing for AHPs includes a process for validating the background and assessing the qualifications of each health care professional. The process should be an objective evaluation of a person’s current licensure, training or experience, competence, and ability to perform the services or procedures requested.

All people applying for AHP privileges should be required to complete an application and delineation of privilege form. The application should be accompanied by a letter from their sponsoring physician, proof of current licensure, registration, or certification, and proof of professional liability insurance coverage. Primary source verification must be obtained prior to the application being presented to the credentials committee, executive committee, and governing board for final approval. Be sure to get the applicant’s written permission to obtain information from other facilities and to conduct police and/or credit checks if required.

You’ll want to query the National Practitioner Data Bank to determine if the AHP has had any reported adverse actions. But remember, hospitals and other health care entities are not required to report adverse actions related to AHPs. For this reason, the databank may not be the best source of information about nonphysicians.

The patient care responsibilities of allied health professionals should be clearly defined. This definition may take the form of specified clinical privileges or a detailed description of the patient care duties they are allowed to perform. The basic education requirements, minimal amount of formal training needed, and scope of practice should be defined for each AHP category. People who are required by law to practice under a sponsoring physician (for example, physician assistants or advanced nurse practitioners) should have a written agreement with that physician as well as jointly agreed upon protocols.

To develop a list of privileges for an AHP, ask sponsoring physicians to provide the medical staff credentials committee with a list of common duties AHPs are qualified to perform. Also, find out what professional associations recommend as the scope of practice for AHPs. Even if a person has a current credential, that does not mean privileges automatically are granted for all requested procedures. Just like licensed physicians, AHPs should be asked to provide evidence of the number of procedures previously performed and outcome data.

Also, check out your state hospital licensing laws. These laws vary from state to state and they dictate what types of practitioners may be members of the organized medical staff. The practitioner’s license or registration will define the exact limits of his or her activities. The scope of an AHP’s license is the starting point for your hospital to define the scope of patient care permitted.

However, AHPs are not automatically entitled to provide all services for which they may be licensed. The governing body, with input from the medical staff, ultimately is responsible for the approval of delineated clinical privileges, whether or not the AHP is a member of the medical staff. For example, what a physician assistant does in a physician’s private office may be entirely different than the duties he or she is allowed to perform in a hospital.

Independent health professionals should be reappointed in the same manner as other practitioners who have been granted clinical privileges, i.e. reappointment application, evaluation of current clinical competence, and peer review recommendation. Dependent practitioners without clinical privileges usually are evaluated through a process similar to an employee evaluation. An AHP working under the direct supervision of a physician should have his or her work evaluated through the same quality monitoring process as the physician.

It is becoming much more common for hospitals to collect quality data on allied health professionals, whereas in the past many did not distinguish the AHP’s quality measures from those of the supervising physician. This separate identification can be accomplished fairly simply with either a unique identifier number for the AHP or by adding a modifier code to the supervising physician’s number.

The AHP’s personal track record of performance within your hospital should be evaluated during the reappointment process. To assess current competence when considering reappointment, the credentials committee can consider information such as the following:

  • clinical activity;
  • medication usage;
  • findings of departmental monitoring and evaluation activities;
  • risk management data;
  • resource management data;
  • data on timeliness of medical record completion;
  • complaints against the professional;
  • morbidity and mortality statistics;
  • outcomes of procedures performed.

The true purpose of credentialing is for the benefit of our patients. Credentialing is your hospital’s most direct means of ensuring that patients receive quality care. It influences care quality by ensuring that patients receive care only from qualified practitioners. Although credentialing requires time and resources, the alternative is far worse — an adverse event or outcome for the patient and liability exposure for your facility. Effective nonphysician credentialing helps protect patients and the organization.